Communication Consent

You can now register to receive information by text message on your phone regarding appointments and health care.

If you wish to register for this messaging service please fill out the consent form below.

Communication Consent Declaration

I consent to the practice contacting me by text message and/or email for the purposes of health promotion, practice news and for appointment reminders.

Yes, I confirm my consent to participate in this service

No, I do not consent

I acknowledge that appointment reminders by text are an additional service and that they may not be sent on all occasions but that the responsibility for attending appointments or cancelling them still rests with me. I can cancel the text message facility at any time. Text messages are generated using a secure facility but I understand that they are transmitted over a public network onto a personal telephone and as such may not be secure, however the practice will not transmit any information which would enable an individual patient to be identified.

I have read and understood what is written above

Your Details

First name

Last name

Date of birth

Mobile Number

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 The Atherstone Surgery • 1 Ratcliffe Road, Atherstone, Warwickshire, CV9 1EU.

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.