Dissent from secondary use of GP patient identifiable data

Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)

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

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

and I will notify you should I change my mind.

Personal Details

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

Privacy Consent

This form collects personal and medical informanot tion about you. 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.


There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.