Register your type 1 opt out preference

Are you completing this form on behalf of: *

Yourself

Someone else

Patient First Name(s): *

Patient Surname: *

Your Full Name: *

Relationship to Patient: *

Phone Number: *

Email Address: *

Address:

Postcode:

NHS Number:

Your Decision

Please select one of the following: *

Opt Out: I do not allow my identifiable patient data to be shared outside of the GP practice for purposes except my own care. Or I do not allow the patient above’s identifiable patient data to be shared outside of the GP practice for purposes except their own care.

Withdraw Opt-Out (Opt-In): I do allow my identifiable patient data to be shared outside of the GP practice for purposes beyond my own care. Or I do allow the patient above’s identifiable patient data to be shared outside of the GP practice for purposes beyond their own care

Your Declaration

I confirm that: *

The information I have given in this form is correct

Please select one of the following: *

I am completing this form for myself

I am the parent or legal guardian of the dependent person I am making a choice for

Signature: *

Date:

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Your Decision

Your Declaration