The Acorn Group Practice

29-35 Holly Road, Twickenham, TW1 4EA

Current time is 23:14 - Sorry, we're closed

Telephone: 020 8891 0073

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Consent to Summary Care Record

Consent to Summary Care Record

Name
First Last
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
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Yes – I would like a Summary Care Record and express consent for medication, allergies, adverse reactions and additional information
- YES
Yes – I would like a Summary Care Record and express consent for medication, allergies and adverse reactions only
- YES
No – I would not like a Summary Care Record
- NO
Express dissent for Summary Care Record (opt out).
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Getting through on the phone
Speaking to a doctor on the phone
Speaking to a nurse on the phone
Obtaining test results by phone

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously