Register your type 1 opt out preference

Are you completing this form on behalf of: Required

Yourself

Someone else

Patient First Name(s): Required

Patient Surname: Required

Phone Number: Required

Email Address: Required

Address:

Postcode:

NHS number:

Your Decision:

Please select one of the following: Required

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: Required

The information I have given in this form is correct

Please select one of the following: Required

I am completing this form for myself

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

Tell us whether you accept cookies

Your Decision:

Your Declaration: