Summary Care Record Opt-Out Form

Services in general practice and the community are being transformed to make it easier for you to access a wider range of help from your surgery.

This is part of the NHS Long Term Plan to offer people further choice and more joined-up healthcare.

Patient's Details

Name
MM slash DD slash YYYY

Carer's Details

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

NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency.

Your records will stay as they are now with information being shared by letter, email, fax or phone.

If you have any questions, or if you want to discuss your choices, please phone the Summary Care Record Information Line on 0300 123 3020; contact your local Patient Advice Liaison Service (PALS); or contact the practice.

Privacy Protection
Consent

FAQs

Please note that we will not respond to any medical information or questions received through the survey.
The information you supply us will be used lawfully, in accordance with the Data Protection Act 1998. The Data Protection Act 1998 gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.
The internet is not a secure place, however, we have gone to great steps in making sure the information you submit to us is as secure as possible.

We use SSL (Secure Socket Layer) certificates to encrypt the communication between your computer and our web server. When you submit your information, it is safely transmitted over the web in an encrypted form and deciphered using the private key at its intended location.