Communications Opt Out Form

It is practice policy that all new patients are automatically opted in to receive text messages from the practice, so we may keep in touch with you to better manage your health and wellbeing.

Not only is it a quick and low-cost way for the NHS to contact patients, but it also saves them time waiting on the phone to get through to the Practice or having to visit the surgery.

However, if you wish to opt-out of this free service, please complete and submit this form.

Your Details

Name *

Date of Birth *

Phone Number *

Email Address

Opting out of receiving Communications from the Practice

Confirm your preference to opt out here: *

I confirm that I wish to opt out of receiving SMS text and email communications from The Barcellos Family Practice

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Page last reviewed: 13 October 2024
Page created: 14 October 2026

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Communications Opt Out Form

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