Communication consent form – Whitchurch Road Surgery

Please complete the online form below to receive updates from the practice by text or email.

Name(Required)

First Last

Date of birth(Required)

Home phone number

Mobile phone number

Email address(Required)

Enter Email Confirm Email

Can we contact you by text message?

Yes

Can we contact you by email?

Yes

Not for urgent medical help(Required)

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

This field is for validation purposes and should be left unchanged.