ADVANCE NOTICE – 26th September 2023 – Practice Closure

The practice will be closed on Tuesday 26th September 2023 from 12:00 to 18:30. Pre-booked appointments from 18:30 will go ahead as planned. We will be open as normal on Wednesday 27th September 2023 from 08:30 am. If your condition is urgent, please dial 111. If you have a critical medical emergency please dial 999.

Castle Place Practice > Forms > Keep us up to Date > Summary Care Record Opt-out Form

Summary Care Record Opt-out Form

This is a summary of basic information about your health which might be important if you need urgent medical care when your GP surgery is closed, or when you go to an accident and emergency department. It means that all NHS staff looking after you can get important information about your health, even if they cannot contact your GP surgery.

Summary Care Record Opt-Out

Section A – Patient’s Details

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Address *

Address

Town/City

County

Postcode

Country

NHS Number

Are you completing this form on behalf of another person or child? *

Yes

Section B – Complete this section of you are completing the form on behalf of another person or child

Your full name *

Relationship to patient *

Signature

Your Signature *

Clear

Please sign your name to confirm. You may draw with mouse, stylus, touch or select the “Type It” option to type your signature.

Date of signature

Today’s date is automatically inserted here.

Privacy Notice

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Notice to discover how we protect and manage your submitted data.

Your consent *

I consent to the practice collecting and storing my data from this form.

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ADVANCE NOTICE – 26th September 2023 – Practice Closure

Summary Care Record Opt-out Form

Section A – Patient’s Details

Section B – Complete this section of you are completing the form on behalf of another person or child

Signature

Privacy Notice

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