Summary Care Record Opt-Out

CORONAVIRUS VACCINE ANNOUNCEMENT

If you are over 80 years of age, a frontline health or social care worker please get your COVID vaccination. Simply contact your GP practice and they will book you in at the next available slot.

If you DO NOT want a Summary Care Record please ﬁll out the form. Your clinical information will be withheld from the Summary Care Record.

Section A

Title

Full Name

Date of Birth

Contact Number

Address

Postcode

NHS Number

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 in section A and your details in section B.

Section B

Title

Full Name

Relationship to Patient

Confirmed opt out

I do not want my information to be shared. I am aware that NHS healthcare staff caring for me may not be aware of my current medications, allergies I suffer from and any bad reactions to medicines that I have had, in order to treat me safely in an emergency.

I have read and agree to the website privacy policy

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