Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *EmailConfirm EmailDate of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please use format day/month/year e.g. 12/05/1979Phone NumberPlease use only numbersYour ConsentI consent to the practice contacting me by text message or email for the purposes of health promotion, practice news and for appointment reminders.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.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.I understand I can cancel the text message facility at any time.Privacy Policy This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. Data Storage *I consent to the Practice collecting and storing my data from this formI DO NOT consent to the Practice collecting and storing my data from this formSend...
