TEXT MESSAGING and E-MAIL CONSENT FORM

The practice is planning to introduce a mobile texting and e-mail communication service. 

This service will be used to send text and e-mail reminders to patients regarding upcoming appointments, requests to attend for repeat tests, speak to the doctor / nurse or book an appointment. We may also use this service to contact patients about health promotion.

We always strive to maintain confidentiality of your information and will continue to do so while using this system. To help us do this, it is important that you let us know if you change your mobile number or email address in the future.
	
If you give consent for us to communicate with you by mobile text messaging and / or e-mail as outlined above please fill in your details below. If you decide you no longer wish to receive messages through this service please inform us.

Patient Name:  	 x_________________________________		EMIS Number:	 ____________

Date Of Birth:	 x___________

Mobile Number: 	 x_____________________				
(and/or)
E-mail: 		 __________________________________

I confirm that I have read and understood the information above and consent to receiving mobile and / or e-mail messages as indicated above from Woodbrooke Medical Practice.

Signature of Patient:  	__________________________________	Date:		____________
(or Parent / Guardian)