Consent Form

Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)

Important

Please complete this form in BLOCK capitals if you are requesting medical information to be given to anyone other than yourself (e.g. a relative)

Please complete all names in full. No initials

Please fill out only one form per person

Personal Details
Please double check you've entered the correct email address
May be used to identify you
Processing
I Hereby consent to the disclosure of my private medical information to
Please only tick one statement below that is applicable
Patient's Consent

I am aware that this consent may be revoked by me at any time, in writing to the Practice Manager

Processing

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Processing

There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.

Care Quality Commission
Rating: Good

Yalding Surgery
Yalding
Kent
ME18 6ES

Telephone: 01622 814380

Facebook