Summary Care Record - Marcham Road Family Health Centre

If you are registered with a GP practice in England you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.

Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals that do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.

You have the choice of what information is included in your Summary Care Record and authorised healthcare staff can only view your SCR with your permission unless it is a medical emergency and you are unable to give permission. The information shared will solely be used for the benefit of your care.

Your options are outlined below. Please note that it is not compulsory for you to complete this consent form. If you choose not to complete a consent form, a Summary Care Record containing information about your medication, allergies, adverse reactions and additional further medical information will be created for you.

Your SCR options:

Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies and adverse reactions only
Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies and adverse reactions and further medical information that includes: Your significant illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.
Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.

SCR Patient Consent Form

Having read the above information regarding your choices, please choose one of the options below and submit form to your GP Practice:

Yes – I would like a Summary Care Record

Express consent for medication, allergies and adverse reactions only.

OR Express consent for medication, allergies, adverse reactions and additional information.

Express dissent for Summary Care Record (opt out). (No – I would not like a Summary Care Record.)

Name

First Last

Address

Street Address Address Line 2 City postcode

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: Optional

Name:

Please choose one:

Parent Optional

Legal Guardian Optional

Lasting power of attorney for health and welfare Optional

If you require any more information, please visit http://digital.nhs.uk/scr/patients or phone NHS Digital on 0300 303 5678 or speak to your GP practice.

Email Optional

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