Type 1 Opt Out

The data held in your GP medical records is shared with other healthcare professionals for the purposes of your individual care. It is also shared with other organisations to support health and care planning and research.

If you do not want your personally identifiable patient data to be shared outside of your GP practice for purposes except your own care, you can register an opt-out with your GP practice. This is known as a Type 1 Opt-out.

Type 1 Opt-outs may be discontinued in the future. If this happens then they may be turned into a National Data Opt-out. Your GP practice will tell you if this is going to happen and if you need to do anything. More information about the National Data Opt Out.

You can use this form to:

Register a Type 1 Opt-out, for yourself or for a dependent (if you are the parent or legal guardian of the patient) (to Opt – out)
Withdraw an existing Type 1 Opt-out, for yourself or a dependent (if you are the parent or legal guardian of the patient) if you have changed your preference (to Opt – in)

This decision will not affect individual care and you can change your choice at any time, using this form.

Details of person completing the form

First Name *

Last Name *

Email *

Date of Birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Are you completing this on behalf of a dependant? *YesNo

e.g. a child. Please note the Practice will first confirm that you have the authority to do so

Dependant Details

Dependant’s First Name *

Dependant’s Last Name

Dependant’s Address *

Your relationship to your dependant *

NHS Number

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *I consent to the practice collecting and storing my data from this form.