Register your Type 1 Opt-Out Preference

We have been asked to share the following important information with you.

This practice is supporting vital health and care planning and research by sharing your data with NHS Digital. For more information about this see the GP Practice Privacy Notice for General Practice Data for Planning and Research (www.digital.nhs.uk – General Practice Data for Planning and Research (GPDPR)).

This collection will start on 1 July 2021. If you do not want your data to be shared with NHS Digital please register your Type 1 Opt Out with your GP practice by September 2021.

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Patient Details

Are you completing this form on behalf of: *

Yourself

Someone else (e.g. a child or dependent)

Patient Full Name: *

Patient Date of Birth: *

Your Full Name: *

Your Relationship to the Patient: *

Your Phone Number: *

Address:

Postcode:

NHS Number:

Your Decision

Please select one of the folowing: *

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)

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Date:

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Register your Type 1 Opt-Out Preference

Patient Details

Your Decision

Your Declaration

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