Register your type 1 opt out preference

Required fields are labelled

Would you like to sign in with NHS login?

Information:

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Who are you completing this form for? Required

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name? Required

First name

Last name

What is your date of birth? Required

For example, 31 3 1980

Day

Month

Year

What is your sex? Required

As recorded on your medical record

Male

Female

Other

What is your postcode? Required

The one used to register with your GP

What is your phone number? Required

What is your email address? Required

Anyone else with access to your email account may see responses sent to you

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:

The information I have given in this form is correct
I am the parent or legal guardian of the dependent person I am making a choice for set out above (if applicable)

Signature: Required

Date:

If you are human, leave this field blank.

Available Forms

If your enquiry is urgent and cannot wait, please call Reception on 01452 617295 and they will be happy to assist you. Alternatively, please visit our online Treatment Room or online Wellbeing and Health Directory for further healthcare support, including Mental Health Services and local Pharmacy information. And you can also seek further information and advice from NHS 111.

We apologise for any inconvenience this may cause and would like to thank you for your continued support and cooperation.

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Register your type 1 opt out preference

Would you like to sign in with NHS login?

Your Decision

Your Declaration

Available Forms