Registration Form for Online Services Please circle as appropriate: I like to book appointments online YES/NO I would like to order repeat prescriptions online YES/NO I would like to be sent text reminders of appointments YES/NO I can be contacted by email YES/NO Forename Surname Date of birth Mobile Number (by providing a mobile number you give consent for Biggar Medical Practice to remind you about routine screening and appointments by text message) Email Address Please write clearly (by providing an email address you give consent for Biggar Medical Practice to contact you by email about routine screening) I will inform the practice if I change my home address, email address, home phone number or mobile phone number Signed Date
Registration Form for Online Services Please circle as appropriate: I like to book appointments online I would like to order repeat prescriptions online I would like to be sent text reminders of appointments I can be contacted by email YES/NO YES/NO YES/NO YES/NO Forename Surname Date of birth Mobile Number (by providing a mobile number you give consent for Biggar Medical Practice to remind you about routine screening and appointments by text message) Email Address (by providing an email address you give consent for Biggar Medical Practice to contact you by email about routine screening) Please write clearly I will inform the practice if I change my home address, email address, home phone number or mobile phone number Signed Date
Registration%20Form%20for%20Online%20Services%202017.docx