Summary Care Record Preference - Empingham Medical Centre

Summary Care Record Opt Out Form 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 the form below.

Summary care record preference: 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.

Opt In/ Opt Out of sharing your Enhanced Summary Care Records

Opt in

Opt Out

Opting Into Enhanced Summary Care Records means that your GP can share key clinical information from your medical records with other clinicians that will require access should they be involved in providing treatment to you whilst under their care.

Title

Mr/Mrs…

First Name

Last Name

Address

Street Address Address Line 2 City Postcode

Date of Birth

Contact Number

NHS number (if known) Optional

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.

First Name Optional

Last Name Optional

Relationship to Patient Optional

Email Optional

This field is for validation purposes and should be left unchanged.