The Summary Care Record Opt Out

Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies.

This means they can give you better care if you need health care away from your usual doctor’s surgery, for instance in A&E or when you’re on holiday.

If you agree, we will include additional information in your Summary Care Record. This will help you get better care when you are away from the GP practice.

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

Please note: If you do not allow us to include additional information in your Summary Care Record, your care may be harmed if you get seriously ill. 

Summary Care Record Opt Out

Are you completing this form on behalf of

About you

Name
The one used to register with your GP.
DD slash MM slash YYYY
Your date of birth is required to verify your identity.
Sex
As on your medical record.
The practice may use this number to contact you about your request.
This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.