Summary Care Record Opt-out Form – Special Allocation Service

Summary Care Record Opt-Out

Section A – Patient’s Details

First Name *

Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Address *

Address

Town/City

County

Postcode

Country

NHS Number

Are you completing this form on behalf of another person or child? *

Yes

Section B – Complete this section of you are completing the form on behalf of another person or child

Your full name *

Relationship to patient *

Signature

Your Signature *

Clear

Please sign your name to confirm. You may draw with mouse, stylus, touch or select the “Type It” option to type your signature.

Date of signature

Today’s date is automatically inserted here.

Privacy Policy

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.