Opt Out of Your Care Connected Form

Patient Details (Stage 1 of 2)

Fill up this form, if you do not want your information to be shared. If you wish to opt out on behalf of any another person or a child, you must put the request through this form. However, we may decline your request if we believe it is not in the best interests of the child or another person in question.

Full Name

Date of Birth (For example, 31 3 1980)

Contact Number (Mobile)

Email Address

Address

I do not want my information to be shared via Your Care Connected. I understand that this may mean important information will not be available to those treating me, when making decisions about my treatment in potentially urgent and life-threatening situations. I understand that by opting out of Your Care Connected, I will also opt out of any other local sharing initiatives by default. I also understand that if I change my mind, I can only opt back in by visiting my GP Practice.

Yes

I consent to being contacted via the details given above. I agree to the privacy policy.

Yes