NIGHTINGALE PATIENTS – CLICK HERE TO SUBMIT A TRIAGE REQUEST

From Monday the 16th of October, Nightingale medical centre will be moving to a total triage system. This means, to access an appointment you will need to fill in a triage request. Once the request has been triaged we will contact you with the outcome, this may be an appointment with a clinician or it

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Dr Laliwala & Partners > Your Record > Keep us up to Date > Communication Consent Form

Communication Consent Form

We would like to keep be able to send you Practice communications by email and text message, but first we need your permission. Please provide your details and consent below. Do not use this form if you are not the patient. If you are a Carer or Patient’s representative please contact the Practice for advice.

Communication Consent

Which Practice are you registered with?

First Name *

Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Mobile Phone Number *

Your Consent

We need to have your consent to begin communicating with you by text or email. Please tick to accept in the boxes below.

I consent to the practice contacting me by text message or email for the purposes of health promotion, practice news and for appointment reminders.

I acknowledge that appointment reminders by text are an additional service and that they may not be sent on all occasions but that the responsibility for attending appointments or cancelling them still rests with me.

Text messages are generated using a secure facility but I understand that they are transmitted over a public network onto a personal telephone and as such may not be secure.

I understand I can cancel the text message facility at any time.

Privacy Policy

This form collects your name, date of birth, email and other personal information. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

Patient’s Signature

Clear

NIGHTINGALE PATIENTS – CLICK HERE TO SUBMIT A TRIAGE REQUEST

Dr Laliwala & Partners

Communication Consent Form

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