Register your type 1 opt out preference Patient DetailsAre you completing this form on behalf of: Yourself Someone else (e.g. a child or dependent) Patient First Name:Patient Surname:Date of Birth DD slash MM slash YYYY Your Telephone OptionalYour Email Address Address (including Postcode)NHS Number OptionalYour DecisionPlease select one of the following: 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. Withdraw Opt-Out (Opt-In): 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 Your DeclarationI confirm that: The information I have given in this form is correct.SignatureTodays Date DD slash MM slash YYYY Phone OptionalThis field is for validation purposes and should be left unchanged.