Summary Care Record - Dr Syed Zaidi & Associates

Request for my clinical information to be withheld from the Summary Care Record.

If you DO NOT want a Summary Care Record, please complete this form. If you are completing this form on behalf of another person or child, please ensure you provide their details in section A and your details in section B.

Summary Care Record Opt-Out Form

Please select the practice location most relevant to this Online Form submission:

Patient's Details

Name

Prefix First Last

Address

Street Address Address Line 2 City Postcode

Phone

NHS Number Optional

Date of Birth

Carer's Details

Name

Prefix Optional First Optional Last Optional

Relationship to patient Optional

Further Information

What does it mean if I DO NOT have a summary health care record? NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency. Your records will stay as they are now with information being shared by letter, email, fax or phone. If you have any questions, or if you want to discuss your choices, please phone the Summary Care Record Information Line on 0300 123 3020; contact your local Patient Advice Liaison Service (PALS); or contact the practice.