*REGISTRATION* – Cholmley Gardens Medical Centre

Summary Care Record - You have the choice of what information you would like to share and with whom. *ONLY* Authorised healthcare staff can view your SCR with your permission. The information shared will solely be used for the benefit of your care. *

Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies for adverse reactions only.
Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies for adverse reactions and further medical information that includes: your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.
Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care. If you chose not to complete this consent form, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions.

Summary Care Records are an electronic record of important patient information, created from GP medical records. If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past. Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs. Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.

Patient Signature *

Please write your name or parent/carer for under 16s

Confirmation *

I agree to switch my registered GP practice.

By confirming, you are consenting to leave your current NHS GP practice. You are free to change your NHS GP practice at any time.

Registration

The personal information we keep about you is to help us provide health or social care or treatment, under the Data Protection Act (DPA) 2018.

Anyone can register with us

Next of Kin / Emergency Contact

Health Questionnaire