My Summary Care Record Choice (Adelaide St)

Last Updated: 21/05/2020

Section A

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.

Title

NHS Number (if known)

Name *

Address *

Postcode *

Phone Number

Date of Brith *

Section B

If you are filling out this form on behalf of another person or a child please ensure you fill out your details here and their details above in section A.

Your name

Relationship to patient

Signature

Date

Summary Care Record Options

YES I would like a Summary Care Record containing details of my medications, allergies and any bad reactions to medications I have had.

YES I would like a Summary Care Record containing details of my medications, allergies and any bad reactions to medications I have had AND any other information that I have agreed with my GP Practice to have included in my Summary Care Records. Please indicate below what information you would like adding if you know.

NO I do not want a Summary Care Record

Please indicate what information you would like adding if you know

If you do not return this form, a Summary Care Record will be created for you based on implied consent.

If you have any questions, or if you want to discuss your choices, please: contact your local Patient Advice Liaison Service (PALS); or contact your GP practice.

What does it mean if I DO NOT have a Summary Care Record?

NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency

Your records will stay as they are now, with information being shared by letter, email, fax or phone.

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My Summary Care Record Choice (Adelaide St)

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