SCR Opt-Out Form

Summary Care Opt-Out Form
Name of Patient
Name of Patient
First
Last
Address
Address
City
County
Postcode
Country
Would you like to Opt-Out of the Summary Care Record programme??
Are you completing this form on behalf of another person?
If 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:
Your authority to complete this document on the patient’s behalf?
(Your Full Name)

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.

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