Summary Care Record Opt-out

Request for my clinical information to be withheld from the Summary Care Record. If you DO NOT want a Summary Care Record please fill out this form.

What does it mean if I DO NOT have a Summary 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.

Summary Care Record Opt-Out

Section A - Patient's Details

First Name *

Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Address *

Address

Town/City

County

Postcode

Country

NHS Number

Are you completing this form on behalf of another person or child? *

Yes

Section B - Complete this section of you are completing the form on behalf of another person or child

Your full name *

Relationship to patient *

Signature

Your Signature *

Clear

Please sign your name to confirm. You may draw with mouse, stylus, touch or select the "Type It" option to type your signature.

Date of signature

Today's date is automatically inserted here.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

If you are human, leave this field blank.

Watlington & Chalgrove Surgeries

What does it mean if I DO NOT have a Summary Care Record?

Section A - Patient's Details

Section B - Complete this section of you are completing the form on behalf of another person or child

Signature

Privacy Policy

About us

Essentials

Contact Us

Brook Surgery

Chiltern Surgery

Subscribe to Practice News