Data Sharing Opt-in/Opt-out

If you are happy for us to share electronic information with clinicians in other NHS organisations who are involved in your care, please complete the form below. If you would rather we didn’t, we will put an entry on your record which will prevent your information from being shared.

It is important to complete this form, as your practice cannot make a decision for you. Without your direction, we cannot guarantee that your wishes will be met, even if you have previously made a similar choice in another practice.

Find out more about Data Sharing.

You must be registered with this practice to submit this form. 

Data Sharing Opt-In/Opt-out

Data Sharing Opt-In/Opt-out

If you are human, leave this field blank.

Your choice for Summary Care Record

I would like my information shared through the Summary Care Record

I do not want my information shared through the Summary Care Record

Please tick one box only

Your choice for Oxfordshire Care Summary

I would like my information shared through the Oxfordshire Care Summary

I do not want my information shared through the Oxfordshire Care Summary

Please tick one box only

Section A

If you are filling this form on behalf of another person or child please ensure you fill their details in section A and your details in section B.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Address (including postcode): *

Phone Number:

Email Address: *

NHS number (if known):

Section B

If you are filling this form on behalf of another person or child please ensure you fill their details in section A and your details in section B.

Your name:

Electronic Signature:

Relationship to patient: