Salford Long COVID Research Consent Form

ICB Name*

Practice ODS Code*

Practice Name*

This is the practice name that will appear in the SMS

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.

Click here to download the Data Processing Agreement. https://mygp.me/334IoNZ

By ticking the box below, you 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 you acknowledge the additional Data Processing Agreement - http://www.iplato.com/dpa.pdf

I agree and consent to the above terms and conditions*

Send me a copy of my responses

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