Summary Care Record Opt Out

Your Summary Care Record contains important information from the record held by your GP practice and includes details of any medicines you are taking, any allergies you suffer from and any bad reactions to medicines that you have previously experienced. Your Summary Care Record also includes your name, address, date of birth and your unique NHS Number to help identify you correctly. As part of a mandatory national programme each GP Practice had to make a summary care record for each patient by March 2015 (unless the patient has already opted out). You can choose to opt out of this scheme at any time. If you wish to opt out of the Summary Care Record scheme please complete the opt out form below.

If you do not want a Summary Care Record please fill in this form.

Summary Care Record Opt-out Form

Section A – Patient’s Details

Name
Name
First
Last
Please use format day/month/year e.g. 12/05/1979
Address
Address
City
State/Province
Post Code

Signature

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.