Summary Care Record Opt Out - Dickenson Road Medical Centre

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.

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.

Full Name

First Last

Date of Birth

Current Address

Street Address Address Line 2 City Postcode

Contact Number Optional

Email Address Optional

NHS Number Optional

(if Known)

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.

Your Name

First Last

Electronic Signature

Print Full Name

Relationship to patient