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Dissent from secondary use of GP patient identifiable data

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Declaration

I am writing to give notice that I: *

To be transferred from your practice systems for any purpose other than my medical care.

Please take whatever steps necessary to ensure: *

Is not uploaded and record my dissent by whatever means possible.

This includes adding the ‘Dissent from secondary use of GP patient identifiable data’ code (Read v2: 9Nu0, CTV3: XaZ89 or SNOMED CT: 827241000000103) to: *

I am aware of the implications of this request, understand it will not affect the care that: *

and I will notify you should I change my mind.

Personal Details

Information to help identify my records [please complete in BLOCK CAPITALS]

If you are unsure of your NHS Number you can find out how to locate it via the NHS website

Privacy Consent

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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