Consent Form

Page {{ paginatorProps.current }} of {{ }} ({{ paginatorProps.percentage }}% completed)
Personal Details
Please double check you've entered the correct email address
May be used to identify you
By leaving any of the following boxes un-ticked, we will assume that consent isn’t given accordingly
I give consent for Waterfield House to contact the following person about any aspect of my medical care and/or treatment:
In accordance with the Data Protection Act, Waterfield House Practice needs consent from a patient. If we do not have consent, we will be unable to send you a message or get in touch with third a party, (unless it is thought to be a medical emergency).

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.