SCR Opt-Out - Ashburnham Road Surgery

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.

If you do not want a Summary Care Record please fill in this form.

Having read the above information regarding your choices, please choose one of the options below and return the completed form to your GP Practice:

Would you like a Summary Care Record?

Yes

No (Opt-Out)

I would like my Summary Care Record to…

Express consent for medication, allergies and adverse reactions only

Express consent for medication, allergies, adverse reactions and additional information

Name of Patient

First Last

Address

Street Address Address Line 2 City Postcode

Date of Birth

NHS Number Optional

Signature

(Full Name)

Are you filling this form out on behalf of someone else?

Yes

Your Name

First Last

Relationship to Patient

Parent

Legal Guardian

Lasting power of attorney for health and welfare

If you require any more information, please visit http://digital.nhs.uk/scr/patients or phone NHS Digital on 0300 303 5678 or speak to your GP practice.

Thank you for your feedback.