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.
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.