Summary Care Record

Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies. This means they can give you better care if you need health care away from your usual doctor’s surgery, for instance in A&E or when you’re on holiday. If you agree, we will include additional information in your Summary Care Record. This will help you get better care when you are away from the GP practice. If you wish to opt out of the Summary Care Record scheme please complete this form. Please note: If you do not allow us to include additional information in your Summary Care Record, your care may be harmed if you get seriously ill.

Are you completing this form on behalf of:

Yourself Optional

Someone else (e.g. a child or dependent) Optional

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.

Patient Full Name:

Patient Date of Birth:

Your Phone Number:

Your Email

Patient Address (including postcode): Optional

Patient NHS number (if known): Optional

Section A

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