Summary Care Records Opt Out Form Having read the above 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 Optional Express consent for medication, allergies, adverse reactions and additional information Optional No – I would not like a Summary Care Record Express dissent for Summary Care Record (opt out) Optional How Can We Reach YouWe would love to chat with you. How can we get in touchName First Optional Last Optional Address Street Address Optional City Optional ZIP / Postal Code Optional Date of BirthDay OptionalDay12345678910111213141516171819202122232425262728293031Month OptionalMonth123456789101112Year OptionalYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NHS Number (if known) OptionalToday's DateMonth OptionalMonth123456789101112Day OptionalDay12345678910111213141516171819202122232425262728293031Year OptionalYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If 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:Name First Optional Last Optional Please select 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