Patient Survey

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Consent to Summary Care Record

Opening Times

Monday
07:30 until 18:30
Tuesday
07:30 until 18:30
Wednesday
07:30 until 20:15
Evening Surgery with Advanced Nurse Practitioner
Thursday
07:00 until 18:30
Phlebotomy Services available from 7am
Friday
07:30 until 18:30
Saturday
CLOSED
Sunday
CLOSED

Consent to Summary Care Record

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
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).
Signature
NHS Number (if known)
NOT THE PATIENT?
If you are filling out this form on behalf of another person, please ensure that you fill out their details above; you sign the form above and provide your details below:
Name
First Last
Relationship to Patient
- Parent
- Legal Guardian
- Lasting Power of Attorney
Email
This field is for validation purposes and should be left unchanged.

	Very easy	Fairly easy	Not very easy	Very difficult	N/A
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