Personal data withdrawal of consent form

The General Data Protection Regulation (GDPR) 2016 provides you, the data subject with the right to withdraw the data we hold about you at any time. The withdrawal of consent shall not affect the lawfulness of processing based on consent before its withdrawal.

Please complete the form below if you wish to withdraw the consent.

Case referral no *

Surname *

First name(s) *

Employee No. *

Telephone Number (Work) *

Email Address (Work) *

Line Manager Name *

Line Manager Employee No.

Line Manager Telephone No. (Work)

Line Manager Email Address (Work) *

1.1 Details of the person requesting the withdrawal (if not the data subject)

Are you acting on behalf of the data subject? *

If “Yes” please state your relationship with the data subject (e.g. parent, legal guardian or solicitor) *

Please enclose proof of identity (letter of authority, letters or official forms addresses to you on behalf of the data subject or power of attorney) that you are legally authorised to withdraw the consent.

Surname *

First name(s) *

Current address *

Telephone Number (Home)

Telephone Number (Work)

Telephone Number (Mobile)

Email Address *

* Denotes a required field