Opt out of receiving research text messages

Please complete this form to indicate that you do not want to receive text messages inviting you to take part in research

Name

First Last

Date of Birth

First line of your address

Postcode

Please choose your surgery

Moss Valley Medical Practice (Eckington)

Gosforth Valley Medical Practice (Dronfield)

Please select the most appropriate answer from the options below

I DO NOT wish to receive text messages regarding research

I am happy to continue receiving text messages regarding research