Pilch Lane Surgery

Patient National Data Opt-Out Form

The NHS may use confidential patient information for research and planning to improve services. The National Data Opt-Out allows you to choose whether your confidential patient information is used for these purposes. This will not affect your care or treatment.

Full Name*

Date of Birth*

NHS Number*

Address*

Contact Number

Your Choice

I am happy for my confidential patient information to be used* YesNo

Important Information

• Your choice will not affect your care.
• Some data may still be used where required by law or public interest.
• You can change your decision at any time.

Declaration

By ticking this box, I declare that I am happy to submit the above information* Yes

Date*

Send

For Practice Use Only