Electronic Communication Consent
If requested by a staff member at Winston Hills Medical Centre, please fill out this form to authorise us to send clinical documents to your email address. Please ensure that your details match the information that we hold on file for you. For security reasons your device's IP address has been logged.
Email *
Title *
First Name *
Middle Name
Last Name *
Date of Birth *
MM
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DD
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Phone Number
Address
Yes, I confirm that I am the above named person or their authorised guardian and consent to Winston Hills Medical Centre sending me clinical documents to the email address given. *
Required
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