Summary Care Record Opt-Out Form

Request for my clinical information to be withheld from the Summary Care Record

If you DO NOT want a Summary Care Record, please complete this form. If you are completing this form on behalf of another person or child, please ensure you provide their details in section A and your details in section B.

1 Patient's Details

please specify
If you know your NHS Number, please provide it
Please provide in the format DD/MM/YYYY

2 Carer's Details

Further Information

What does it mean if I DO NOT have a summary health 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 phone the Summary Care Record Information Line on 0300 123 3020; contact your local Patient Advice Liaison Service (PALS); or contact the practice.

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and TLS (using a 2048 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

All form submissions are sent directly to our practice via e-mail. No data is stored on the server.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Northbrook Health Centre - 93 Northbrook Road, Shirley, Solihull, B90 3LX
Dickens Heath Medical Centre - 94 Old Dickens Heath Road, Dickens Heath, Solihull, B90 1SD
Supplied by Central Midlands CSU
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