Type 1 Opt-out Form

Are You?

The Patient

A Parent / Legal Guardian of the Patient

Patient’s Details

Title:

Mrs

Miss

Mstr

Other

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Date of Birth

MM slash DD slash YYYY

NHS Number (if known) Optional

Type 1 Opt-out preference

Opt-Out: I do not allow my identifiable patient data to be shared outside of the GP practice for purposes except my 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

Your decision

Opt-out

Withdraw Opt-out (Opt-in)

Signature

I confirm that the information I have given in this form is correct.

Proof of ID

Accepted file types: jpg, jpeg, png, gif.

Email Preferance

I want a copy of the contents of this form to be emailed to me Optional

Practice Confirmation

I confirm that I am a registered patient at CROSBY HOUSE SURGERY