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.

Summary Care Record Opt Out

Summary Care Record Opt Out

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: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Address (including postcode):

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Please note that your email address will be saved as part of your contact details in your medical records. We may contact you via your email address if you become locked out of your online account and need your password sent, or to send you health questionnaires.

In future we may send you clinical letters via email instead of as a posted letter for speed and to reduce our carbon footprint. You can opt-out of this by telling the Practice.

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 Signiture:

Relationship to patient: