Contact Details for Patients at Parsons Heath Medical Practice

What is your e-mail address?

What is your full name?

What is your home phone number?

What is your date of birth?

Birth Day:

Birth Month:

Birth Year:

What is your mobile phone number?

What is your work phone number?

What is the best way to contact you between 8am and 6.30pm Monday to Friday Surgery Opening Hours?

Home Phone Number	Work Phone Number
Mobile Phone Number	Email

What is the second best way to contact you between 8am and 6.30pm Monday to Friday Surgery Opening Hours? We will need to use this if we fail to make contact by your first choice

Home Phone Number	Work Phone Number Number
Mobile Phone Number Number	Email

Have you a history of or are you suffering from any of the following? Please check all that apply:

Asthma Epilepsy	Heart Disease Hypertension
Chronic Obstructive Airways Disease	Diabetes

For patients who have chronic health problems we would like to be able to use email to remind them if they are due for a check up or if they are due flu vaccines or blood tests for example. Please tick yes if you can be contacted by your email address for this purpose. Tick no if you do not want us to contact you in this manner. Remember if you give us permission to contact you in this way to consider if there is a problem if other people have access to your email as this may be a worry if you are concerned about confidentiality.