Birmingham and Solihull Friends and Family Test Programme 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.

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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