Summary Care Record Opt Out

Your Summary Care Record contains a brief summary of key information from the medical record held by your GP practice. It is limited to information that would be of use to a health professional looking after you in any NHS service outside of the practice and was designed to aid patient care, prevent avoidable harm and delays in treatment. It contains details of any regular medicines you are taking and any allergies or serious adverse 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 has made a summary care record available for each patient since 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 this opt out form.

If you are human, leave this field blank.

Section A

If you are filling this form on behalf of another person or child please ensure you fill their details in section A and your details in section B.

Full Name: *

Address (including postcode):

Phone Number:

NHS number (if known):

Section B

If you are filling this form on behalf of another person or child please ensure you fill their details in section A and your details in section B.

Your name:

Electronic Signature:

Relationship to patient:

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