Village Health Group - Text Reminder Consent Form

This form is intended for our patient to use if they wish to consent/dissent to Village Health Group sending SMS messages.

Last Updated: 26/07/2022

Your Details

Please select the branch you are registered with: *

East Leake

Keyworth

Ruddington (Church House)

Sutton Bonington

Name *

Date of Birth *

Mobile Number *

Email Address *

Do you consent to receiving text messages from Village Health Group? *

Yes No

Signed: *

Dated: *

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.

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Village Health Group - Text Reminder Consent Form

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