Heartburn Health programme opt-out form

Fields marked with an asterisk* are mandatory

Your first name *

Your middle name

Your last name * Family name

Your date of birth *

Day

Month

Year

Gender *

Your postcode * You must enter the home postcode you registered with your GP surgery and include a space in the middle. For example EN1 1BE.

Your NHS number You can find your NHS number at https://www.nhs.uk/nhs-services/online-services/find-nhs-number/

Why do you wish to opt out? We use this information to better understand patient attitudes to data sharing and improve our future communications.

This is an opt-out form

You should only submit this form if you do not wish to be invited to take part in the research programme.