Forms

Contact Preferences Form

We would like to offer patients new ways of contacting and communicating with the surgery.

In order to benefit, we need the following information:

Fields marked * are required.

Name: *

Date of birth: *

Day: Month: Year:

Home Telephone: *

Can we leave you a voicemail message? *

Yes: No:

By choosing 'Yes' you will be giving consent.

Mobile Telephone: *

Can we leave you a voicemail message? *

Yes: No:

Can we send you a text message? *

Yes: No:

By choosing 'Yes' you will be giving consent.

Email: *

Can we contact you by email? *

Yes: No:

By choosing 'Yes' you will be giving consent.

If you are not the named patient and are providing this information WITH THEIR PERMISSION, please provide us with your name:

Your Name:

Thank you for taking the time to complete this form. We may contact you if we have any queries that arise from this form.

In the meantime, if you wish to call us, you can do so on 0845 477 3543.