Summary Care Record Consent Form

Last Updated: 10/06/2020

Your Details

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 here and your own in the next section.

Title

NHS Number (if known)

Surname *

Forename(s) *

Address *

Postcode *

Phone Number

Date of Birth *

Consent

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

Summary Care Record Options *

I do not wish to share my health record with other healthcare services providing care for me.

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. You can enter this information in Question 2.

NO I do not want a Summary Care Record.

Please indicate what information you would like to add, if you are not sure you can just choose to share a brief summary.

Your name if you are completing this form on behalf of someone else. *

Relationship to patient *

Date *

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 your local Patient Advice Liaison Service (PALS) or contact your GP practice.

Completing this form

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form. *

Yes No

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Summary Care Record Consent Form

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