Summary Care Records Opt Out Form Request for my clinical information to be withheld from the Summary Care Record. If you DO NOT want a Summary Care Record please complete this form. Title Forename(s) Surname Address Street Address Street Address Line 2 City County Postcode Telephone number Date of birth / Day / Month Year NHS Number (if known) Signature Clear B. If you are filling out this form on behalf of another person or a child, their GP practice will consider this request.Please ensure you fill out their details in section A and your details in section B Name First Name Last Name Signature Clear Relationship to patient Date - Day - Month Year 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 RecordInformation Line on0300 123 3020;• contact your local Patient AdviceLiaison Service (PALS); or• contact your GP practice. Preview PDF Submit Should be Empty:
