Summary Care Record Opt-Out

What does it mean if I DO NOT have a summary care record?

Health-care staff treating you may not be aware of your current medications in order to treat you safely and effectively. Health-care staff treating you may not be made aware of current conditions and/or diagnoses leading to a delay or missed opportunity for correct treatment. Health-care staff may not be aware of any allergies/adverse reactions to medications and may prescribe or administer a drug/treatment with adverse consequences.

If you DO NOT want a Summary Care Record, please ﬁll out the form. Your clinical information will be withheld from the Summary Care Record.

A

Title

Full Name

Date of Birth

Contact Number

Address (including postcode)

NHS Number (if known) Optional

B

If you are ﬁlling out this form on behalf of another person or a child, their GP practice will consider this request. Please ensure you ﬁll out their details in section A and your details in section B.

Title Optional

Full Name Optional

Relationship to Patient Optional

Summary Care Record Opt-Out

Summary Care Record Opt-Out

A

B

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