Type 1 Opt-out Form Register your Type 1 Opt-Out Preference Your DetailsName First Last Date of Birth Day Month Year Contact NumberEmail Enter Email Confirm Email PostcodeNHS Number (if known) 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 I am the parent or legal guardian of the dependent person I am making a choice for set out above (if applicable) SignatureDate Day Month Year GP PRACTICE CODING INSTRUCTIONOpt Out – Dissent code: 9Nu0 (827241000000103 Dissent from secondary use of general practitioner patient identifiable data (finding). Opt In – Dissent withdrawal code: 9Nu1 (827261000000102 Dissent withdrawn for secondary use of general practitioner patient identifiable data (finding)Phone OptionalThis field is for validation purposes and should be left unchanged.