Summary Care Record (SCR) Patient Preference Form - Thornbury Road Centre for Health

Having read the information regarding your choices on the Join our GP Surgery page, please choose one of the options below and return the completed form to the GP Practice you are registered with:

No – I would NOT like a Summary Care Record

Opt-out of Summary Care Record

Yes – I would like a Summary Care Record

Express preference for medication, allergies and adverse reactions only.

Express preference for medication, allergies, adverse reactions and Additional Information

Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth

NHS Number (If Known) Optional

Signature

Date

If you are filling out this form on behalf of another person, please ensure that you fill out their details above; you sign the form above and provide your details below:

Name Optional

Leave blank if you are NOT filling out this form on behalf of another person.

Relation To Patient

Parent

Legal Guardian

Lasting power of attorney for health and welfare

If you require any more information, please e-mail enquiries@nhsdigital.nhs.uk or call NHS England Enquiries on 0300 303 5678, or speak to the GP practice.