Summary care record choices

Summary Care Record Choices

Patient Address (including postcode): *

NHS Number (if known):

Having read the important information regarding your choices, please choose one of the options below:

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

Yes – I would like a 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:

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