My Summary Care Record Choice (Adelaide St)

Last Updated: 21/05/2020

Section A

If you are filling out this form on behalf of another person or a child, their GP practice will consider this request. Please ensure you fill out their details in section A and your details in section B.








Section B

If you are filling out this form on behalf of another person or a child please ensure you fill out your details here and their details above in section A.







If you do not return this form, a Summary Care Record will be created for you based on implied consent.

If you have any questions, or if you want to discuss your choices, please: contact your local Patient Advice Liaison Service (PALS); or contact your GP practice.