Summary Care Record Opt Out

Your Summary Care Record is designed to help other medical professionals who may need to care for you but are not familiar with your medical history, such as district nurses or the ambulance service. It includes as a minimum:

• Your name
• Date of birth
• NHS number
• Current medication
• Adverse reactions to medications
• Allergies

You can choose to opt out of this scheme at any time. However, doing so will mean that those treating you in an emergency may not be aware of your allergies or current medications and therefore may not be able to treat you safely

If you still wish to opt out of the Summary Care Record scheme, please complete this form.

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.

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: