Summary Care Record 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:Would you like a Summary Care Record? Yes No (Opt-Out) I would like my Summary Care Record to… Express consent for medication, allergies and adverse reactions only Express consent for medication, allergies, adverse reactions and additional information Name of Patient First Last Address Street Address Address Line 2 City Postcode Date of Birth DD slash MM slash YYYY NHS Number Optional Signature (Full Name)Are you filling this form out on behalf of someone else? Yes No Your Name First Last Relationship to Patient Parent Legal Guardian Lasting power of attorney for health and welfare 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.