Consent to receive clinic letters

Consent to receive Clinic Letters via Email
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address

Street Address

Street Address Line 2

CityCounty

Postcode
My correspondence preference

I wish to receive clinic letters via access code email
I wish to receive clinic letters by Royal Mail
Email address to send correspondence to*
example@example.com
Consultant
Clinic letters will be sent to you via a coded protected email. The code to open your email is generated below. A copy of this form will be emailed to you when you press the submit button.
Your unique code to open your email will be (a copy of this will be emailed to you during office hours. Please keep this code for all future use):
Should be Empty:

Consent to receive Clinic Letters via Email