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Home
econsult
Patient Advice
About Us
Online Forms
News
Menu
COVID-19
Prescriptions
Patient Record
New Patients
Recruitment
NHS App
Text Reminder Consent Form
Last Updated: 25/09/2019
Your Details
Name
*
Date of Birth
*
Mobile Number
*
Email Address
*
THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU. 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.
Submit Form
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