I N S O N
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Dr Janet Cooke MBChB DRCOG MRCGP
Dr Andrew Brewer BSc MBBS
Dr Ian Heatley MBChB DRCOG DOccMed
440 Kinson Road Kinson Bournemouth BH10 5EY Tel: 01202 574604
Fax: 01202 590029
Extraction of Confidential Data for the Health & Social Care Information Centre (HSCIC)
Please tick as appropriate
I confirm that I DO NOT want any confidential data being extracted from my GP medical record and used by the Health & Social Care Information
Centre.
I confirm that I DO NOT want any confidential data leaving the Health &
Social Care Information Centre.
Name: ……………………………………………………Date of Birth: …………
(Please print)
Address:…………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………
Signed: ……………………………………………Date: …………………….
__________________________________________________________
Action by Surgery:
Read code 9Nu0 has been added to this patient’s record to ensure no data is extracted.
Read code 9Nu4 has been added to this patient’s record to ensure no data is extracted
Signed: ………………………………….. Name: …………………………..
Date a ctioned: …………………………………..
Branch Surgery: West Howe Clinic Cunningham Crescent Bournemouth BH11 8DN Tel: 01202 581981