Data sharing opt in/opt out

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

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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

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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):

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:

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