This Form is Currently Unavailable

There is currently a technical issue with this form.
We are doing all we can to correct this.
Please return at a later date, or, if urgent, contact the Practice.

Home Page

COMMUNICATION CONSENT FORM

I consent to the practice contacting me by text message and/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. I can cancel the text message facility at any time.

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, however the practice will not transmit any information which would enable an individual patient to be identified.

Your Details

Full Name: Date of Birth (patients only): Home Telephone Number: Mobile Telephone Number: Email Address:

Confirm your Location

I confirm that I am a patient at Bolingbroke Medical Centre, Battersea, London.

Information provided by you through this form will allow us to improve our services. The form data undergoes encryption during transmission and while at rest, and will only be retained for a duration sufficient to process your request. You have the option to withdraw your request at any time by notifying the practice. By using this form you are agreeing to our privacy guidelines.

Send Your Request

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form