Summary Care Record – Bartley Green Medical Practice

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.

A

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.

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

A

B

Incorrect Info