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Sign Up For Text Message Reminders

Please complete the form to sign up for text message reminders. Please be aware that your number will be registered on our system with your consent for us to send information to you in this way. If you change mobile numbers, or pass your phone to another person, it is your responsibility to tell us, otherwise, that person may receive the information intended only for you to your nominated number.
Some older children may wish to change consent for this service to their own mobile phone number. In this instance they must complete a new consent form at the practice.
You may withdraw consent at any time by notifying reception.

Title *
Mr Mrs Miss Ms Other
Name * First Last
Date of Birth * / DD / MM YYYY
Gender *
Male Female
Address *

Street Address Address Line 2 Town/City County/Region Postcode Country
Email *
Mobile Phone Number *
Home Phone Number