Your emergency care summary

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CONFIDENTIAL

SUMMARY CARE RECORD and OXFORDSHIRE CARE SUMMARY opt-out form

Request for clinical information to be withheld from the national Summary Care Record
and/or the local Oxfordshire Care Summary

ONLY COMPLETE THIS FORM IF YOU DO NOT want a Summary Care Record AND/OR an Oxfordshire Care
Summary. Send the competed form to your GP Practice.

IF YOU ARE COMPLETING THIS ELECTRONICALLY PLEASE E-MAIL BACK TO:

registrations.nbs@nhs.net
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A. Please complete in BLOCK CAPITALS

Title...................................................................... Surname/Family Name ..................................................................

Forename(s) ....................................................................................................................................................................

Address ..........................................................................................................................................................................

Postcode ............................ Phone No .................................................. .Date of Birth .............................................

NHS Number (if known)............................................................ Signature.....................................................................

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B. If you are filling out this form on behalf of another person or child, their GP Practice will consider this
request.
Please ensure you fill out their details in section A and your details in section B.

Your name ...................................................................... Your signature ....................................................................

Relationship to patient .................................................... Date......................................................................

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C. Your Choice the table below lists your options; please indicate your decision by placing a tick in the final
column

Oxfordshire Care Summary Summary Care Record Your choice (please tick)

1. YES I want one AND X NO thanks Combination 1:

2. X NO thanks AND YES I want one Combination 2:

3. X NO thanks AND X NO thanks Combination 3:

If you DO want both of these records, you do not need to do anything they will automatically be created for you.
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FOR NHS USE ONLY

Actioned by Practice yes/no Date........................................