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Heartburn Health Check - Consent Form

Heartburn Health Check procedure

Consent form V1 February 2026

Please complete this form if you would like to volunteer in the Heartburn Health Check procedure.

The appointment testing is designed to check the appointment process from start to finish, Including, checking that consent is in place, and conducting the capsule sponge test in the presence of an accredited trainer.

By agreeing to take part as a volunteer in the procedure, I understand that:

- I am under no obligation to volunteer

- I can change my mind at any point

- My real personal data (name, address, date of birth) will not be used or retained.

- I will have the capsule sponge test administered by one of the pharmacy team.

Confirmation of choice I have read the statements above and have had any questions answered.

I agree to volunteer in the test procedure

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Your legal name

Your email address

Please Confirm full name and signature.

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February 24, 2026 10:22 am BST

Heartburn Health Check - Consent Form Uploaded by Tap Tarika - [email protected] IP 109.145.51.95

February 24, 2026 10:23 am BST

TPIR Inbox - [email protected] added by Tap Tarika - [email protected] as a CC'd Recipient Ip: 109.145.51.95

February 24, 2026 10:25 am BST

TPIR Inbox - [email protected] added by Tap Tarika - [email protected] as a CC'd Recipient Ip: 109.145.51.95

February 24, 2026 10:26 am BST

TPIR Inbox - [email protected] added by Tap Tarika - [email protected] as a CC'd Recipient Ip: 109.145.51.95