Abbey Meads Medical Group

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Contact By Email Consent

Introduction:

If you are happy for us to contact you periodically by email please complete the form below.


Contact By Email Consent:

Patient Identification:

Firstname (1st 3 Chars): *

Surname (1st 3 Chars): *

Date of Birth (dd/mm/yyyy): *

 /   / 

Contact Information:

Email Address: *

About You:

The additional information below will help to make sure we try to speak to a representative sample of the patients that are registered at this practice.

Gender: *

Male  Female

Age Group: *

Under 16

17 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65 - 74

75 - 84

Over 84

Ethnicity: *

How would you describe how often you come to the practice?: *

Regularly Occasionally
Very Rarely

Terms & Conditions:

Please confirm by ticking the box below that you have read and accept our Terms & Conditions for using this online facility to send us your consent for us to contact you by Email:

Instructions

Are my details secure ?

The Internet is not a secure medium. Please refer to our privacy page for further details. If after reading this you do not wish to use this service, please utilise one of the other methods detailed on our Contact by Email Consent page.


Why are you asking people for their contact details?

We would like to be able to contact people occasionally to ask them questions about the surgery and how well we are doing to identify areas for improvement.


Other Notes:

All fields marked with * are mandatory.