Communication consent form – Town Gate Practice

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

Your contact details

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

Communication Consent

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

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.