Receive reminders when you are due for a check-up or an
appointment!
Email and Text message consent Form for Victoria Medical Practice
Name ______________________________________________
Email Address______________________________________________
Tel______________________________ Mobile_________________________
Victoria Medical Practice offers our patients the opportunity to receive practice correspondence by
email and SMS text message. This form provides information about the risks of email and texts,
guidelines for email and text communication and how we will use email and text communication.
Benefits
There are a number of advantages to contacting patients via email:
 Quick and easy communication without delays
 Reduced possibility of loss of communication through incorrect postal address
Risks
 Communication by email and text has a number of risks which include, but are not limited to,
the following:
 Email and texts can be circulated, forwarded and stored in paper and electronic files.
 Backup copies of email and texts may exist even after the sender or the recipient has deleted
his/her copy.
 Email and text can be received by unintended recipients.
 Email and text can be intercepted, altered, forwarded or used without authorisation or detection.
 Email and text senders can easily type in the wrong email address or mobile number.
 Email and texts can be used to introduce viruses into computer systems or smart phones.
How we will use email and texts
1) We will limit email and text correspondence to established patients who are adults 16 years or older,
or the legal representatives of established patients. We will also communicate with parents or
guardians of patients under 13 who have registered their email with us. Once children reach their 13th
birthday this facility will be removed and the mobile number provided will be used to contact the patient
by telephone. This is to ensure that patient confidentiality is maintained as best as possible. The
requesting parent/guardian must be registered at the same address as the child in order to access this
service. The service is not available for 13 to 15 year olds, although they will be able to re-register in
their own right from their 16th birthday.
2) We will use email and texts to communicate with you only about non-sensitive and non-urgent
issues such as:
 Recall screening for patients with long-term conditions
 Appointment scheduling
 General non-urgent correspondence
All emails and texts to you will be made a part of your medical record. You will have the same right of
access to such emails and texts as you do to the remainder of your medical file.
3) Your email and text messages may be forwarded to another office staff member as necessary for
appropriate handling.
4) We will not disclose your email address or mobile phone number to anyone outside the practice.
5) Email communication is not intended to be used as a form of two-way communication – it is solely
for the purpose of sending you electronic correspondence. Only respond to texts where asked to in the
text message.
Please do not reply to any emails, always contact the practice by telephone or face-to-face. In a
medical emergency, please do not use email. Call the emergency services. Also, do not use
email for urgent problems. If you have an urgent problem, call the surgery or go to an urgent care
facility.
Guidelines for email communication
1. We will include the general topic of the message in the “subject” line of your email. For example,
“prescription,” or “appointment”.
2. You will be expected to send us an email confirming receipt of our message after you have received
and read an email message from us (failure to acknowledge emails by ignoring a request for a read
receipt may prevent us from sending any further emails)
3. Take precautions to protect the confidentiality of email, such as safeguarding your computer
password and using screen savers.
4. Inform us of changes in your email address.
5. Please be aware that if you share your email address with another recipient the information we send
to you may be viewed by them. We will not be responsible for breach of information. It is your
responsibility to ensure your email address and password is confidential and personal to you.
Consent
I, ___________________________________,
(print name)
am:
a) an established patient of Victoria Medical Practice
b) the legal representative of an established patient, _______________________________
(print patient’s name)
 I consent to receiving electronic correspondence from Victoria Medical Practice by email and
text message. I understand the risks of communicating by email and text messages, in
particular the privacy risks explained in this form. I understand that Victoria Medical Practice
cannot guarantee the security and confidentiality of email or text communication. Victoria
Medical Practice will not be responsible for messages that are not received or delivered due to
technical failure, or for disclosure of confidential information unless caused by intentional
misconduct.
 I understand that I may also communicate with Victoria Medical Practice by telephone or during
a scheduled appointment, and that email is not a substitute for care that may be provided
during normal surgery hours. Appointments should be made to discuss any new issues or any
sensitive medical information.
 I understand that either I or Victoria Medical Practice may stop using email or text messages as
a means of communication upon my written request.
 I understand that I may revoke this consent at any time by advising Victoria Medical Practice
either verbally or in writing.
 My revocation of consent will not affect my ability to obtain future health care.
 I have read and understand this form. I have had the opportunity to ask questions and my
questions have been answered to my satisfaction. I understand and agree with the information
contained in this form and give my consent for email communications to and from Victoria
Medical Practice
____________________________________ (print name)
____________________________________ (signature)
(date)______________________