Choose if your con den al pa ent informa on

is shared for research and planning

Manage your choice, or your

child’s choice on their behalf
Use this form to make a choice for yourself and/or children under the age of 13.

You must be either the child’s:

● parent
or
● legal guardian

You can use this form for up to 6 people.

To make a choice for more than 6 people, ll out as many of these forms as you need
and send them all together.

Once completed you can either email or post this form.

To email this form to our NHS Digital Contact

Centre please use:
enquiries@nhsdigital.nhs.uk
To post the form please send to:
Na onal Data Opt Out
Contact Centre
NHS Digital
HM Government
7 and 8 Wellington Place
Leeds
LS1 4AP

Further details about how the NHS uses health data can be found online at
www.nhs.uk/your-nhs-data-ma ers

For more informa on please read our privacy no ce on our website your-data-
ma ers.service.nhs.uk/privacyno ce
tt
ti
ÿþ(
ti
fi
ÿþ(
ti
tt
ti
ti
fi
ti
ti
 SecFon
Sec on 11
You need
You need your
your and
and your
your child’s
child’s NHS
NHS Number
Number in
in order
order to
to use
use this
this service
service
An NHS number is a 10 digit number.
An NHS number is a 10 digit number.

You can find your or your child’s NHS number on:

You can nd your or your child’s NHS number on:

● prescrip0ons
● prescrip ons
● test results
● test results
● appointment leXers
● appointment le ers
● referral leXers
● referral le ers
● personal child health record (red book)
● personal child health record (red book)

Or you can use the Find Your NHS Number service here:
Or you can use the Find Your NHS Number service here:
hXps://www.nhs.uk/nhs-services/online-services/find-nhs-number/
h ps://www.nhs.uk/nhs-services/online-services/ nd-nhs-number/

Tell us your NHS number. If you are also filling in this form for your
children, please tell us their NHS numbers below too.

Full name NHS Number

Full name NHS Number
This is a 10 digit number
This is a 10 digit number

For more informa0on please read our privacy no0ce on our website your-data-
For more informa on please read our privacy no ce on our website your-data-
maBers.service.nhs.uk/privacynoFce
ma ers.service.nhs.uk/privacyno ce
tt
tt
ti
ti
fi
tt
tt
ti
ti
ti
ÿþ(
fi
 Sec on 2
SecFon
Your details

Full name

Address
your GP
This must be your address you have registered with your GP surgery.
surgery.

Sec on 3
SecFon

Sec on 3
SecFon
Tell us your choice

children’s confiden0al
The choice you are making is whether your and your children’s con den al pa0ent
pa ent
informa on can be used for:
informa0on

● nd cures and beXer

research to find be er treatments for
for illnesses
illnesses

● planning where we need to improve or provide

provide more
more health
health services
services

a ect your (or

This decision will not affect or your
yourchildren’s)
children’s)individual
individual care
care and
and you
you can
can
change your choice at any 0me.
me.

Yes, I allow my and/or

and mymychild or children’s
child(ren)’s con denpa0ent
confiden0al al pa ent
informa0on
informa on to be used for research
to be used for research and planning and planning

No, II do notdoallownomy
t and/or
alow my
mychild(ren)’s
and m y’s con
chd
il denpa0ent
confiden0al oral pa chent
ildren
informa on to be used for research and planning
informa0on planning

Sec on 4
SecFon
declara on
Your declaraFon

con rm that:
I confirm
informa on I have given in this form is correct
● the informa0on correct
child or
● I am the parent or legal guardian of any child or children
children II am
am
making a choice for

Signature

Date signed

informa on please read our privacy no0ce

For more informa0on no ce on
on our
our website
website your-data-
your-data-
ma ers.service.nhs.uk/privacyno
maBers.service.nhs.uk/privacynoFcece
tt
fi
ti
ti
ti
ti
ti
ti
ti
ti
fi
ti
ti
ff
ti
tt
ti
ti
fi
ti
fi
ti
ti
ti
fi
ti
ti
 Sec on 5
If you would like con rma on of your choice please provide your email
address in the box below. Postal con rma on is not available at
present.
Email address:

Once completed please use the contact details to email or post this form to
us.

To email this form to our NHS Digital Contact

Centre please use:
enquiries@nhsdigital.nhs.uk
To post the form please send to:
Na onal Data Opt Out
Contact Centre
NHS Digital
HM Government
7 and 8 Wellington Place
Leeds
LS1 4AP

For more informa on please read our privacy no ce on our website your-data-
ma ers.service.nhs.uk/privacyno ce
tt
ti
ti
ti
fi
ti
ti
ti
fi
ti