Data Sharing

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

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: *

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 Signature:

Relationship to patient:

Please note that the details you give will be used to update your medical records. If your correct contact information is not entered we will not be able to respond to you.

If you are human, leave this field blank.

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

• Patient.co.uk
• NHS
• Health & Social Care Information Centre 
• An alternative view written by a GP