Emergency Care Summary Record Opt-out Form

Most patients in Scotland now have an Emergency Care Summary containing basic information about your health in case of an emergency.

NHS staff can also use your Emergency Care Summary if your GP refers you to an outpatient clinic or for admission to hospital to check your details.

Emergency Care Summary Record Opt-Out

Section A – Patient’s Details

First Name *

Last Name *

Email *

Enter 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 Policy

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 Policy to discover how we protect and manage your submitted data.

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

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Emergency Care Summary 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 Policy

Local support

Self-help

Services directory

Closure

Engage Your Visitors!

Closure

Emergency Care Summary 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 Policy

Local support

Self-help

Services directory