Confidentiality consent form with declaration

Do you understand why we have asked you for your mobile/telephone number and email address? *
Are you are happy for us to communicate with you using these methods? *

Communication consent

We use your contact details to send confirmations and reminders for appointments, test results, requests for contacting the service and for post treatment feedback surveys to improve patient experience.
Do you consent to Dorset Healthcare using your contact details for the above reasons? *
Do you give consent for communication by telephone? *
Do you give consent for communication by SMS message? *
Do you give consent for communication by email? *
Is there a parent/carer who should receive a copy of correspondence? *

Communication support needs

Do you have a communication support need? *
Please state your preferred language *
Most of our clients are contacted by email. Do we need to contact you in a different way? *
Do you need information presented in a different format? E.g. easy-read, Braille, audio. *
Do you need an interpreter? *
Do you use a communication aid? *
Please tick each box to confirm you have read the following information. *
Screening forms