Care Home Resident Form (only required for care home residents)

Title *

Full Name *

Date Of Birth *

Previous Surname(s) if Applicable *

Marital Status *

Gender *

NHS Number

Address *

Temporary or Permanent Resident? *

Temporary

Permanent

What date is the patient moving into the Care Home? *

Has the resident moved to the home following hospital discharge? *

Yes No

Does the resident give consent to share their medical record with other health and social care providers (for example: RD&E, the care home)? *

Yes No

Does the patient have a current up-to-date TEP Form? (If yes, please send us a copy.) *

Yes No

Next of Kin/Emergency Contact

Power of Attorney

Vitals and Lifestyle

NHS Summary Care Record

Your Summary Care Record (SCR) is a copy of key information held in your GP record includes important information about your health.

• Medicines you are taking

• Allergies you suffer from

• Any bad reactions to medicines

You may need to be treated by health and care professionals that do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs. Having a SCR means that when you need healthcare you can be helped to recall vital information.

SCRs can help the staff involved in your care make better and safer decisions about how best to treat you.

NHS Summary Care Record with additional information

You can also choose to have additional information included in your SCR, which can enhance the care you receive. This information includes:

• Your illnesses and health problems

• Operations and vaccinations you have had in the past

• How you would like to be treated - such as where you would prefer to receive care

• What support you might need

• Who should be contacted for more information about you

What does it mean if I do not have a summary care record?

NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency.

For more information please visit https://www.digital.nhs.uk/summary-care-records/patients, call NHS Digital on 0300 303 5678

Title *

Full Name *

Address *

Date of Birth *

Signature *

If you are filling out this form on behalf of another person or a child, their GP practice will consider this request. Please circle Yes or No and fill out the below.

Yes No

Your Name *

Relationship to Patient *

Your Signature *

Date *

Please choose an option *

I want an SCR WITH additional information (Express consent for medication, allergies, adverse reactions and additional information .eg. diagnosis and medical history)

I want an SCR WITHOUT additional information (Express consent for medication, allergies and adverse reactions only)

I DO NOT want an SCR (Express dissent for Summary Care Record (opt out))

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Care Home Resident Form (only required for care home residents)

Further Information