National Data Type 1 Opt- Out Type 1 Opt-out Preference Details of the patientTitle OptionalMrMrsMissMsDrFore Name OptionalSurname OptionalDate of Birth Optional DD slash MM slash YYYY Contact Number OptionalEmail Optional Address (including postcode) OptionalNHS Number (if known) OptionalDetails of parent or legal guardianIf you are filling in this form on behalf of a dependent e.g. a child, the GP practice will first check that you have the authority to do so. Please complete the details below:Full Name OptionalRelationship OptionalAddress OptionalIf you are filling in this form on behalf of a dependent e.g. a child, the GP practice will first check that you have the authority to do so. Please complete the details below: 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. Optional Opt-in (Withdraw Opt-out): 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. Optional Consent I confirm that the information I have given in this form is correct. Optional I confirm that I am the parent or legal guardian of the dependent person I am making a choice for set out above (if applicable). Optional I agree to being contacted via the details given above. I agree to the privacy policy. Optional