I understand that I can, at any time, request that my personal information not be used for these purposes by contacting:
Email: email@example.com or
write to me at Plas Mawr Community Centre, Highfields, Blackwood, NP12 1HB
While I remain a patient of Geraldine Norris (and for seven years thereafter. In case of children, 7 years after their 18th Birthday), I consent to my personal information being used for the purposes detailed above.
Please tick the boxes below to give me permission to use the information you have supplied in the following ways: