Virtual Group Sign Up Form - Sandwich Medical Practice

Virtual Patient Group - Sign Up Form

Your Details

Name *

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. REQUIRED Answer I consent to the practice collecting and storing my data from this form.

I consent to the practice collecting and storing my data from this form.

Date of Birth *

Phone Number

Email Address *

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Page last reviewed: 08 August 2019
Page created: 21 August 2019

Virtual Patient Group - Sign Up Form

Virtual Patient Group - Sign Up Form

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