Coronavirus SMS Campaign: Consent Form
Sign in to Google to save your progress. Learn more
Email *
Please complete the once off registration and consent form below in order for us to set up your automated SMS Campaigns and send to your customers on behalf of your Pharmacy. *
Your Name: *
Pharmacy Name: *
Pharmacy BHF / Practice Number: *
Pharmacy Contact Number: *
Pharmacy WhatsApp Number
Another way to communicate with your Patients. If you need assistance, contact us.
Pharmacy Email Address: *
Please select the LIST OF PATIENTS you would like to SMS *
I'd like to choose the following Message Options: *
Short SMS Options are 20 Cents per Credit Per Patient. Long SMS Options are 40 Cents per Credit Per Patient. - All excluding VAT.
What do you think about this service for your Pharmacy?
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy