Register your Type 1 Opt-Out Preference Your DetailsName First Last Date of Birth Day Month Year Contact NumberEmail Enter Email Confirm Email Postcode NHS Number (if known) Optional Your 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) Signature Date 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 Opt In – Dissent withdrawal code: 9Nu1 (827261000000102 Dissent withdrawn for secondary use of general practitioner patient identifiable data (finding)Name OptionalThis field is for validation purposes and should be left unchanged.