Local Opt Outs

Last Updated: 03/06/2021

Your Details

Full Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

NHS Number (if known) (optional)
Opt Outs

You can find more information about our data systems and policies on our website. You can opt out of your data being transferred out of the Practice for any of these schemes. If you wish to opt out of any of the above please tick the relevant options, sign below and hand the form to reception. (optional)

I wish to opt out of my data being uploaded to the national ‘Summary Care Record’

I wish to opt out of the local ‘Connecting Care Record’

I wish to opt out of the ‘Local Record Sharing’

Confirmation (optional)

I confirm I am the above patient or their legal guardian and authorised to submit this request on their behalf.

Your Name

Date
For example, 15 3 1984

Day

Month

Year

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.