Summary Care Record OptOut – Wychall Lane Surgery

Summary Care Record Opt-Out

If you DO NOT want a Summary Care Record please ﬁll out the form. Your clinical information will be withheld from the Summary Care Record.

Title

Full Name

Date of Birth

Contact Number

Address

Postcode

NHS Number

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.

Title

Full Name

Relationship to Patient

Confirmed opt out

I do not want my information to be shared. I am aware that NHS healthcare staff caring for me may not be aware of my current medications, allergies I suffer from and any bad reactions to medicines that I have had, in order to treat me safely in an emergency.

I have read and agree to the website privacy policy

Summary Care Record Opt-Out

Copyright:Wychall Lane Surgery

Copyright:

Wychall Lane Surgery