Patient Consent Form

Tel no. (home):*
Tel no. (mobile):
Providing a mobile number will enable appointment reminders/recalls by our automated text message service
Please tick your preferred method of contact:*

MobileEmailHome phoneLetter
Do you give consent for us to:-
Leave appointment reminders on your HOME contact number?
Send you text and/or email reminders when you have appointments due?
Send you our monthly newsletter by email?
Send you information about our services/offers by email?

Please give details of any persons

who are authorised by you to request information regarding your dental treatment, fees and appointments:
Title
Name*

First NameLast Name
Relationship*
Your relationship to the patient.
Patient/Carer Signature:

Clear
Please use finger or mouse to draw a signature
Date:

DayMonthYear
Date
If you change your mind about how or why we contact you or if your details change, please let a member of our reception team know as soon as possible. Thank you.
Should be Empty:

Do you give consent for us to:-