SMS Consent Form

Please complete this form to advise us of any changes to your address and mobile number and whether you consent to receive information via text message

Please select the practice location most relevant to this Online Form submission:

SMS Consent Form

Patient Full Name

Date of Birth

Address

Mobile Number

Consent to receive information via text message

Email Confirmation

Tick the box if you would like to receive an e-mail confirming the form has been received by Bartholomew Medical Group.

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 Main Surgery • Goole Health Centre, Woodland Avenue, Goole, DN14 6RU.

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.