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Text form Hassengate Medical Centre

VIEWS: 14 PAGES: 1

									                                         HASSENGATE MEDICAL CENTRE
      Southend Road                                                               GP Partners
      Stanford-le-Hope                                                            Dr N J Tresidder
      Essex. SS17 0PH                                                             Dr K J Hanson
      Tele. 0844 477 8945                                                         Dr A O’Doherty
      Fax 0871 226 4360                                                           Dr J M Pusey
                                        Mr R J Vine, Practice Manager / Partner   Dr M Szczekot

                                         Text Messaging Service
      We are please to be able to offer all our patients with a mobile telephone a text messaging
      service. This service will allow us to send you information such as appointment reminders
      and results of tests. The system will also allow you to conveniently communicate by text
      message will us 24hours a day – for example to cancel an appointment that you can no
      longer attend, although you can already do this by a normal telephone call if you wish.

      The system is totally secure and all data is encrypted to protect your confidentiality

      In order for you to benefit from this new system, please complete and sign the consent
      form below and return it to us with the other registration papers. Once you are registered
      onto the text service we will send you a welcome message and further instructions on how
      to use the system.

      We will not share your information with anyone else, nor will we text you unless you
      complete and return the form.

      If you do decide to make use of this system, you must inform us if you change your mobile
      number or indeed want to stop using the service. In this circumstance please either
      telephone us, text us or drop in and let us know.

      The only cost to you of this system is the cost of a text – the cost is set by your mobile
      telephone provider, please contact them to find out the cost of the text.


      Name                              ………………………………………………………………
      Date of Birth                     ………………………………………………………………
      Address                           ………………………………………………………………
                                        ………………………………………………………………
                                        ………………………………………………………………
                                        ………………………………………………………………

      Home telephone number             ………………………………………………………………

      Mobile telephone number           ………………………………………………………………

      I wish to make use of the Practice Text Messaging system and agree to the practice
      contacting me by text message. I understand it is my responsibility to inform the practice
      should I change my mobile telephone number or wish to cease using this service.


      Signature                         ………………………………………………………………

      Date                              ………………………………………………………………




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