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.

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

Date of Birth

Address

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Full address including postcode

Phone Number Optional

Email Address:

NHS number (if known) Optional

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 Optional

Electronic Signature Optional

Relationship to patient Optional