We are introducing Summary Care Records to improve the safety and quality of patient care.

The Summary Care Record is an electronic record which will give healthcare staff faster, easier access to essential information about you.

For more information about Summary Care Records please copy and paste website address below into your web address from the internet.

http://www.nhscarerecords.nhs.uk/summary/

If you would like to opt out please fill out the form below.

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 fill out the form and send it to your

GP practice

A. Please complete in BLOCK CAPITALS

Title...................................................... Surname/Family name…………………………………….

Forename(s)................................................................................................................................

Address........................................................................................................................................

.....................................................................................................................................................

Postcode............................................... Phone No.....................................................................

Date of birth ………………………………………………

NHS Number (if known)........................................................................................

Signature.............................................

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

Your name............................................................................................................. Your

Signature....................................

Relationship to patient...............................................................................................

Date.....................................................

Actioned by practice: yes/no…………………Date…………………………………..

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;

• contact your local Patient Advice

Liaison Service (PALS); or

• contact your GP practice.