Shotfield Medical Practice
www.shotfieldmedicalpractice.co.uk

Partners:
Dr. Heather Lings 							Jubilee Health Centre
Dr. Bernard Lewis							Shotfield
Dr. Hani Mahfooth							Wallington
Dr. Shilen Pattani							Surrey
Dr. Kaushal Kansagra						             SM6 0HY	
Dr. Elvis Martinez							Tel. No:  020 8669 7612
Salaried GPs:							             
Dr. Laura Rodriguez-Benito
Dr. Alison Sheridan

SUMMARY CARE RECORD

Patient Opt Out Form

This form should be completed by the individual (data subject) making the request.  
Please complete clearly and use block capitals.

TITLE: ………………..	FORENAME: ………………………………………………………..

SURNAME: ………………………………………………………………………………………….

ADDRESS: ………………………………………………………………………………………….

………………………………………………………………………………………………………..

POSTCODE: ………………………….      TEL NO: …………………………….......................

DATE OF BIRTH: …………………………   NHS NO (IF KNOWN): …………………………..

What does it mean if I DO NOT have a summary care record?  Heath care staff treating you may not be aware of your current medications in order to treat you safely and most effectively.  Health care staff may not be aware of allergies and adverse reactions to medications and may prescribe or administer a drug or treatment with adverse consequences.

The core data that we would propose to upload to the summary care record would include medications, allergies and adverse reactions only.  If you have questions or wish to discuss your choices or concerns, please telephone the NHS care records team on 0845 603 8510.  

If you wish to opt out of having your core data uploaded to the summary care record at some point in the future please complete the declaration below and return this form to the practice with your other registration forms.  If you do not object to your core data being uploaded you need do nothing more with regards this form, we only want to know if you DO NOT wish to have your core data uploaded at a future date. 

Please see separate information sheet provided for more information on the Summary Care Record and its benefits before you opt out using this form. 

Signature of patient: ……………………………………………….	Date: ………………………

Printed name of Practice Representative actioning: …………………………………………………

Date of action by practice: ………………………………………….