Summary Care Record Opt-out Form - The Hilltop Medical Practice

Having read the above information regarding your choices, please choose one of the options below and return the completed form to your GP Practice:

Would you like a Summary Care Record?

Yes

No (Opt-Out)

I would like my Summary Care Record to…

Express consent for medication, allergies and adverse reactions only

Express consent for medication, allergies, adverse reactions and additional information

Name of Patient

First Last

Address

Street Address Address Line 2 City Postcode

Date of Birth

NHS Number Optional

Signature

(Full Name)

Are you filling this form out on behalf of someone else?

Yes

Your Name

First Last

Relationship to Patient

Parent

Legal Guardian

Lasting power of attorney for health and welfare

If you require any more information, please visit http://digital.nhs.uk/scr/patients or phone NHS Digital on 0300 303 5678 or speak to your GP practice.