Summary Care Record Opt Out

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.

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

Summary Care Record Opt Out

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.
Name(Required)
First Last
Date of Birth(Required)
Phone Number(Required)
Email Address(Required)
Address (including postcode)(Required)
Address Line 1 Address Line 2 Town/City County Postcode
NHS Number (if known)(Required)
Summary Care Record - Additional Information If you are registered with a GP practice in England, you will have a Summary Care Record (SCR), unless you have previously chosen not to have one. It includes important information about your health: Medicines you are taking Allergies you suffer from Any bad reactions to medicines You may need to be treated by health and care professionals that do not know your medical history. Essentials details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs. Having a SCR means that when you need healthcare you can be helped to recall vital information. SCR's can help the staff involved in your care make better and safer decisions about how best to treat you. You can choose to have additional information included in your SCR, which can enhance the care you receive. The information includes: Your illnesses and health problems Operations and vaccinations you have had in the past How you would like to be treated - such as where you would prefer to receive care What support you might need Who should be contracted for more information about you
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
Relationship to patient:
Signature
What happens to my information?
Personal and medical information about patients registered at Peverell Park Surgery is primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you (please refer to our Privacy Policy), for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.
Consent(Required)
- I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.
Name
This field is for validation purposes and should be left unchanged.

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Peverell Park Surgery

Monday
08:00 to 18:00
Phones open at 08:00 / Doors open at 08:30
Tuesday
08:00 to 18:00
Phones open at 08:00 / Doors open at 08:30
Wednesday
08:00 to 18:00
Phones open at 08:00 / Doors open at 08:30
Thursday
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Phones open at 08:00 / Doors open at 08:30
Friday
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Phones open at 08:00 / Doors open at 08:30
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CLOSED
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CLOSED

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Summary Care Record Opt Out