Records Sharing Consent Form

Patients must consent to the sharing of their data held by one health provider to other health providers. Access to patient data is under the patients' control and can be shared on a 'need to know' basis if required. Your information is NEVER shared to any person or service not involved with your care. The surgery will automatically share information IN so that they can see your information from other care services, but will not automatically share your GP record out without your consent to do so. Please complete your choices below. Please note that we can share confidential information without consent if it is required by law, or directed by a court, or if the benefits to a child or young person that will arise from sharing the information outweigh both the public and the individual's interest in keeping the information confidential.

Last Updated: 02/04/2021

Your Details

Full Name *

Date of Brith *

Address *

Postcode *

Phone Number *

E-mail Address

Record Sharing IN

This controls whether you agree for the practice to view information you've agreed to share at other NHS Care Services. Please record your preference below.

Consent *

I DO wish to share my health record IN to the practice from other healthcare services providing care for me.

I DO NOT wish to share my health record IN to the practice, from other healthcare services providing care for me.

Digitally Signed *

Date *

Record Sharing OUT

This controls whether your full GP electronic patient record can be shared with other NHS Care Services where you are treated. This allows other NHS providers such as secondary care providers, emergency care providers and community care providers with relevant medical information to assist them in providing your care.

Consent *

I DO wish to share my health record OUT of the practice to other healthcare services providing care for me.

I DO NOT wish to share my health record OUT of the practice to other healthcare services providing care for me.

Digital Signature *

Date *

Summary Care Record

Orchard Surgery shares part of your medical records (current medication & allergies) in an emergency, when you're on holiday, when the surgery is closed, at out-patient clinics or when you visit a pharmacy. We can add additional information to your Summary Care Record (SCR) from your medical notes, including: 1) Health problems (eg. Diabetes/Dementia/Stroke etc.) 2) Carer Details 3) Treatment Preferences 4) Communication needs (interpreter/hearing difficulties etc) What does it mean if you DO NOT have an SCR? 1) NHS staff caring for you may not be aware of your current medications and allergies, in order to treat you safely in an emergency. 2) Your records will stay as they are with information shared by letter, email or phone. 3) If you have any questions or if you want to discuss then please contact the surgery. Having read this information, please choose ONE of the options below.

Consent *

YES - I would like a Summary Care Record for medication, allergies and adverse reactions ONLY

YES - I would like a Summary Care Record for medication, allergies and adverse reactions AND additional information

NO - I would NOT like a Summary Care Record. Express dissent NOT to share any Summary Care Record information

Digital Signature *

Date *

Records Sharing Consent Form

Further Information