Opting Out

It is possible to “opt out” of data sharing if you wish. Complete the below form if you wish to refuse data sharing.

Summary Care Record Opt Out

If you are human, leave this field blank.

Section A

If you are filling this form on behalf of another person or child please ensure you fill their details in section A and your details in section B.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Address (including postcode): *

Phone Number: *

Email Address: *

Any responses we send will go to this email address.

NHS number (if known):

Section B

If you are filling this form on behalf of another person or child please ensure you fill their details in section A and your details in section B.

Your name:

Electronic Signiture:

Relationship to patient:

Further useful information about the Care.Data programme is available at:

• Patient.co.uk
• NHS
• Health & Social Care Information Centre