Communication consent form – Town Gate Practice

Please complete the consent form below to receive text messages and/or emails from the practice.

Name(Required)

First name(s) Last name

Date of birth(Required)

Home phone number

Mobile phone number(Required)

Email address(Required)

Enter Email Confirm Email

Can we contact you by text message?(Required)

Yes

Can we contact you by email?(Required)

Yes

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help