Summary Care Record opt out

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:

Address (including postcode):

Phone Number:

NHS number (if known):

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:

Terms and Conditions: *

I confirm that this problem is not an emergency. I understand that the practice will not deal with this problem while the practice is closed.

If the problem worsens and may require immediate help, I will visit NHS 111 Online or call 111. In an emergency, I will call 999.

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