Old Courthouse Surgery - SMS Text Messaging Reminders

SMS Text Messaging Reminders
We are now able to send you a reminder of your appointment by text message to your mobile phone. If you are interested in this, please complete the below form.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Tel:*
Date of birth*

DayMonthYear
Date
This is to confirm that I give consent for Washingborough Surgery to send text
messages to my mobile phone.
I am aware that if I change my mobile phone number, it is my responsibility to inform
the surgery.
I confirm to give my consent
Should be Empty: