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Staunton & Corse Surgery NHS GP Surgery in Gloucestershire

Preferences for receiving emails, text messages and your preferred GP

Section

Do you have a GP you regularly see regarding an ongoing condition? *

Dr M Chambers

Dr B Fisher

Dr S Humphries

Dr C Kingcombe

Dr J Somerton

No preference

If no preference is specified, the practice will allocate you to one of our GPs.

Next of Kin

Next of kin full name: *

Relationship to you: *

Next of kin telephone number: *

Communication Preferences

My email/SMS communication preferences: *

I give consent for communication by email

I give consent for communication by SMS text messaging

I do not want to receive communication by email or SMS

I would like to receive the following by email or SMS: *

Appointment reminders

Appointment letters

Individual invites (e.g. screening, medication reviews, vaccinations)

Test result notifications or advice to call the practice when action is needed

Friends and Family Test surveys

Interactive messages (e.g. confirm or cancel appointments)

All of the above and any surgery specific updates (e.g. Practice Newsletter)

Patient Agreement

Keeping your information secure *

I will be responsible for the security of the information that I receive

Sharing your information *

If I choose to share my information with others, this is at my own risk

If your information is accessed without permission *

I will contact the practice as soon as possible if I suspect unauthorised access

If you feel pressured to share your information *

If I feel pressured to share access unwillingly, I will notify the practice immediately

Signature *

Date

If you are human, leave this field blank.

Gloucester Road
Corse
Gloucester
Gloucestershire
GL19 3RB

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01452 840228

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