Admin: 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.

Please do not write any clinical information on this form. Any clinical information or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day and amend your records as per your request. This process can take up to 5 working days. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Section A

Full Name:

Date of Birth (DD/MM/YYYY):

Telephone Number:

Home Address:

Postcode:

Section B (Only complete if applicable)

Carer's Full Name:

Relationship to patient:

I have gained consent from the patient to complete this form on their behalf.

Confirmation & Further Information

What does it mean if I DO NOT have a summary health 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 phone the Summary Care Record Information Line on 0300 123 3020; contact your local Patient Advice Liaison Service (PALS); or contact the practice.

I confirm that I DO NOT want to have a summary health care record

Privacy Protection

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 and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.