The Denmead Practice Hambledon Road, Denmead, Hampshire, PO7 6NR Tel: 023 9223 9630 Fax: 023 9223 9636 VAT registration No: 878 6398 45 Data Sharing Please complete the information below with your choices on sharing your data and hand to Reception Name: ………………………………………………………………. Date of Birth: ………………… Address: …………………………………………………………………………………………………………………. Data for research ☐ I do not wish identifiable data about me to leave the practice ☐ I do not wish data about me to be shared by HSCIC Summary care Record I do not wish to have a Summary care Record (N.B. this will mean NHS Healthcare staff caring for you may not be aware ☐ of your current medications, any allergies or reactions to previous medication.) Hampshire Healthcare Record ☐ I do not wish to have a Hampshire Healthcare Record Signed:…............................................................ Date:………………………………………………………………
The Denmead Practice Hambledon Road, Denmead, Hampshire, PO7 6NR VAT registration No: 878 6398 45 Tel: 023 9223 9630 Fax: 023 9223 9636 Data Sharing Please complete the information below with your choices on sharing your data and hand to Reception Name: ………………………………………………………………. Date of Birth: ………………… Address: …………………………………………………………………………………………………………………. Data for research I do not wish identifiable data about me to leave the practice ☐ I do not wish data about me to be shared by HSCIC ☐ Summary care Record I do not wish to have a Summary care Record (N.B. this will mean NHS Healthcare staff caring for you may not be aware of your current medications, any allergies or reactions to ☐ previous medication.) Hampshire Healthcare Record I do not wish to have a Hampshire Healthcare Record ☐ Signed:…............................................................ Date:………………………………………………………………
Adult%20Registration%20Form%20Incl%20Data%20Sharing%20Jan%202017.docx