Summary Care Records – Opt Out Form OPT-OUT FORMRequest for my clinical information to be withheld from the Summary Care Record If you DO NOT want a Summary Care Record please fill out the form and send it to your GP practiceTitleMissMsMrsMrotherName First Last Address)PostcodePhoneDate of Birth DD slash MM slash YYYY NHS Number (if known) OptionalSection BIf 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 BYour name OptionalRelationship to patient OptionalWhat 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 GP practiceSignature