Summary Care Record (SCR) Opt Out

If you do not want a Summary Care Record or a Hampshire Healthcare Record, please fill in this form.

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.

Section A

Full Name: *

Date of Birth: *

Address:

Postcode:

Phone Number:

Email Address: *

NHS Number (if known):

Section B

Your name:

Electronic Signature:

Relationship to Patient:

Data for Research

I do not wish identifiable data about me to leave the practice

I do not wish data about me to be shared by HSCIC

Summary Care Record

I do not wish to have a Summary Care Record and am aware this will mean NHS Healthcare staff caring for me may not be aware of my current medications, any allergies or reactions to previous medication

Hampshire Healthcare Record

I do not wish to have a Hampshire Healthcare Record

Adult Health (not children) Check Programme

I agree to being invited for screening programmes by the data processor

I do not agree to being invited for screening programmes by the data processor

Please be aware that the surgery is unable to opt patients out of all screening services. Patients are required to do this directly with the screening services themselves.

or Cancel

Summary Care Record (SCR) Opt Out

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