Summary Care Record Opt Out - Blackmore Vale Partnership

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.

If you have any questions, or if you want to discuss your choices, please contact us.

SCR Opt-out Form

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