Summary Care Record Opt Out

The Summary Care Record (SCR) is an electronic record of important patient health information created from General Practice (GP) medical records. It can be seen and used by authorised staff in the health and care system involved in the patient’s direct care.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 on this page.

If you do not want a Summary Care Record please fill in this form.

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Summary Care Record Opt Out

Summary Care Record Opt Out

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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: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Address (including postcode):

Phone Number:

Email Address: *

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NHS number (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:

Electronic Signature:

Relationship to patient: