Data Sharing Opt-in/Opt-out

If you are happy for us to share electronic information with clinicians in other NHS organisations who are involved in your care, please complete the form below. If you would rather we didn’t, we will put an entry on your record which will prevent your information from being shared.

It is important to complete this form, as your practice cannot make a decision for you. Without your direction, we cannot guarantee that your wishes will be met, even if you have previously made a similar choice in another practice.

Find out more about Data Sharing.

Data Sharing Opt-In/Opt-out

Please tick one box only
Please tick one box only

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

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.