Summary Care Record Consent Form

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.

Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.

Summary Care Record: Patient Consent Form

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Personal Details

Are you completing this form on behalf of: *

Yourself

Someone else (e.g. a child or dependent)

Patient Full Name: *

Your Full Name: *

Relationship to Patient: *

Your Telephone Number:

Your Email Address: *

Address: *

Postcode:

NHS Number:

Your Consent

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care. Your options are outlined below:

a) Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies and adverse reactions only.

b) 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.

c) 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.

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

Yes, I would like a Summary Care Record - Express consent for medication, allergies and adverse reactions only.

Yes, I would like an Enhanced Summary Care Record - Express consent for medication, allergies, adverse reactions and additional information.

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

Signature: *

Date:

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

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Your Consent

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