Count Me In

Opt Out Page 1 of 1 Please check questions marked in red...
Information If you do not want to be told about research opportunities, you can easily opt out and it will not affect your care. You will need to complete this form with the required information, so that we can identify who you are:
First Name
Last Name
NHS Number If you don't know your NHS number you can use this online service to find it: https://www.nhs.uk/find-nhs-number/
Date of Birth
We would like to send you confirmation of your decision to opt out, how would you prefer to receive this?
Reason for opting out
Would you like to provide more information about your decision to opt out? (Optional)
Information: If you have difficulty completing this form, you can: Speak with your clinical team Call 0151 351 8476 for assistance By Email CountMeIn@merseycare.nhs.uk