Register your Type 1 Opt-Out Preference The data held in your GP medical records is shared with other healthcare professionals for the purposes of your individual care. It is also shared with other organisations to support health and care planning and research. If you do not want your personally identifiable patient data to be shared outside of your GP practice for purposes except your own care, you can register an opt-out with your GP practice. This is known as a Type 1 Opt-out. You can use this form to: register a Type 1 Opt-out, for yourself or for a dependent if you are the parent or legal guardian of the patient (to Opt-out) withdraw an existing Type 1 Opt-out, for yourself or a dependent if you have changed your preference (Opt-in) This decision will not affect individual care and you can change your choice at any time, using this form. This form, once completed, should be sent to your GP practice by email or post.Details of PatientName First Last Address Street Address City State / Province / Region ZIP / Postal Code PhoneDate of Birth MM slash DD slash YYYY NHS Number (if known) OptionalDetails of Parent or Legal GuardianIf you are filling in this form on behalf of a dependent e.g. a child, the GP practice will first check that you have the authority to do so. Please complete the details below:Name First Optional Last Optional Address Street Address Optional City Optional State / Province / Region Optional ZIP / Postal Code Optional Relationship to Patient OptionalYour DecisionPlease choose one of the following options: OPT-OUT – I do not allow my identifiable patient data to be shared outside of the GP practice for purposes except my own care. OPT-OUT – 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. OPT-IN – I do allow my identifiable patient data to be shared outside of the GP practice for purposes beyond my own care. OPT-IN – I do allow the patient above’s identifiable patient data to be shared outside of the GP practice for purposes beyond their own care. DeclarationI confirm that: The information I have given in this form is correct. I am the parent or legal guarding of the dependent person I am making a choice for set out above (if applicable) ConsentTHIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. I consent to the practice collecting and storing my data from this form.