Care record form ATitleTitleMrMrsMissMsOtherName First Last Date of Birth DD slash MM slash YYYY Phone Number OptionalPostcodeNHS Number (If known) OptionalIf you are filling out this form on behalf of another person or a child, their GP practice will consider this request. Please ensure you fill out their details in section A and your details in section B.BTitleTitleMrMrsMissMsOtherName First Last Relationship to patientRegister your 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. 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 Second ChoiceOpt-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 Optional Consent I confirm that the information I have given in this form is correct.Consent 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).Consent I agree to being contacted via the details given above. I agree to the privacy policy.CAPTCHA Optional
