Communication Consent

Please complete this form to consent to receive information via text message and/or email

Patient Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

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Contact Details

Home Address

Postcode

Telephone

Mobile

E-mail Address

Consent Preferences

To update your communication consent preferences, select an option below

Consent to receive communications by text message

Consent to receive communications by email

Consent to receive communications by both text message and email

I have previously given consent that I wish to withdraw

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to East Park Medical Practice • Jonesfield Crescent, East Park, Wolverhampton, West Midlands, WV1 2LW.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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