Birmingham and Solihull National Diabetes Prevention Programme Consent Form

Birmingham and Solihull National Diabetes Prevention Programme Consent Form

ICB Name*

Practice ODS Code*

Practice Name*

This is the practice name that will appear in the SMS

Postcode*

Surgery Telephone Number*

This is the GP surgery number that will appear in the SMS

Practice Clinical System*

Select

Full Name*

Position*

Direct Dial*

Email Address*

Confirmation of your sign-up and a copy of the signed DSA will be sent to this email address.

We acknowledge that iPLATO Healthcare will be responsible for the sending of text messages. If you are an existing iPLATO customer, all Terms & Conditions previously agreed to these services remain the same. This programme is an extension of existing iPLATO services and I acknowledge the additional Data Processing Agreement. http://www.iplato.com/dpa.pdf

If you would like to see the Data Sharing Agreement before signing, click HERE:

I agree and consent to the above terms and conditions*

Send me a copy of my responses

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