{"id":1379,"date":"2018-05-02T20:10:48","date_gmt":"2018-05-02T19:10:48","guid":{"rendered":"http:\/\/www.drpolding.scot.nhs.uk\/?page_id=1379"},"modified":"2019-02-09T10:48:53","modified_gmt":"2019-02-09T10:48:53","slug":"summary-care-record-opt-out-form","status":"publish","type":"page","link":"https:\/\/www.drpolding.scot.nhs.uk\/managing-your-health\/update-your-personal-details-forms\/summary-care-record-opt-out-form\/","title":{"rendered":"Summary Care Record Opt-out Form"},"content":{"rendered":"<link rel='stylesheet' id='formidable-css' href='https:\/\/www.drpolding.scot.nhs.uk\/wp-content\/plugins\/formidable\/css\/formidableforms.css?ver=5121254' media='all' \/>\n<div class=\"frm_forms  with_frm_style frm_style_big_text\" id=\"frm_form_25_container\" data-token=\"3da25eb1e713f699ec9ee97d19a568a9\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_hnlsj6311\"  data-token=\"3da25eb1e713f699ec9ee97d19a568a9\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Summary Care Record Opt-Out<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"25\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_25\" id=\"frm_hide_fields_25\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"hnlsj6311\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_25\" name=\"frm_submit_entry_25\" value=\"c4b344490f\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/1379\" \/><div id=\"frm_field_542_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Section A &#8211; Patient&#8217;s Details<\/h3>\r\n\r\n\r\n<div id=\"frm_field_543_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_xu1tj6311\" class=\"frm_primary_label\">First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xu1tj6311\" name=\"item_meta[543]\" value=\"\"  data-sectionid=\"542\" data-reqmsg=\"First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_544_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_xt7az6311\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xt7az6311\" name=\"item_meta[544]\" value=\"\"  data-sectionid=\"542\" data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_545_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_ppbxb6311\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_ppbxb6311\" name=\"item_meta[545]\" value=\"\"  data-sectionid=\"542\" data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_ppbxb6311\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_ppbxb6311\">Enter Email<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_conf_545_container\" class=\"frm_form_field frm_none_container frm_conf_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_conf_ppbxb6311\" class=\"frm_conf_label frm_primary_label\">Confirm Email\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_conf_ppbxb6311\" name=\"item_meta[conf_545]\" value=\"\"  data-sectionid=\"542\" placeholder=\"Please confirm your email\" data-reqmsg=\"Confirm Email cannot be blank.\" aria-required=\"true\" data-confmsg=\"The entered values do not match\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_conf_ppbxb6311\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_conf_ppbxb6311\">Confirm Email<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_546_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_w1eya6311\" class=\"frm_primary_label\">Date of birth\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_w1eya6311\" name=\"item_meta[546]\" value=\"\"  data-sectionid=\"542\" data-frmmask=\"99\/99\/9999\" placeholder=\"DD\/MM\/YYYY\" data-reqmsg=\"Date of birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\\/\\d\\d\\\/\\d\\d\\d\\d$\"   aria-describedby=\"frm_desc_field_w1eya6311\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_w1eya6311\">Please use format day\/month\/year e.g. 12\/05\/1979<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_547_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_spq8l4311\" class=\"frm_primary_label\">Phone Number\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_spq8l4311\" name=\"item_meta[547]\" value=\"\"  data-sectionid=\"542\" data-reqmsg=\"Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_548_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label  class=\"frm_primary_label\">Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <fieldset aria-labelledby=\"field_lza5q_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tAddress<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_548-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_lza5q_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_lza5q_line1\" value=\"\" name=\"item_meta[548][line1]\"  data-sectionid=\"542\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_548-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_lza5q_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_lza5q_line2\" value=\"\" name=\"item_meta[548][line2]\"  data-sectionid=\"542\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_548-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_lza5q_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tTown\/City\t<\/label>\n\t\t<input type=\"text\" id=\"field_lza5q_city\" value=\"\" name=\"item_meta[548][city]\"  data-sectionid=\"542\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">Town\/City<\/div><\/div>\n<div id=\"frm_field_548-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_lza5q_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tCounty\t<\/label>\n\t\t<input type=\"text\" id=\"field_lza5q_state\" value=\"\" name=\"item_meta[548][state]\"  data-sectionid=\"542\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">County<\/div><\/div>\n<div id=\"frm_field_548-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_lza5q_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tPostcode\t<\/label>\n\t\t<input type=\"text\" id=\"field_lza5q_zip\" value=\"\" name=\"item_meta[548][zip]\"  data-sectionid=\"542\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Postcode<\/div><\/div>\n<div id=\"frm_field_548-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_lza5q_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[548][country]\" id=\"field_lza5q_country\"  data-sectionid=\"542\" data-frmval=\"United Kingdom\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\">Afghanistan<\/option><option  value=\"Aland Islands\">Aland Islands<\/option><option  value=\"Albania\">Albania<\/option><option  value=\"Algeria\">Algeria<\/option><option  value=\"American Samoa\">American Samoa<\/option><option  value=\"Andorra\">Andorra<\/option><option  value=\"Angola\">Angola<\/option><option  value=\"Anguilla\">Anguilla<\/option><option  value=\"Antarctica\">Antarctica<\/option><option  value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option  value=\"Argentina\">Argentina<\/option><option  value=\"Armenia\">Armenia<\/option><option  value=\"Aruba\">Aruba<\/option><option  value=\"Australia\">Australia<\/option><option  value=\"Austria\">Austria<\/option><option  value=\"Azerbaijan\">Azerbaijan<\/option><option  value=\"Bahamas\">Bahamas<\/option><option  value=\"Bahrain\">Bahrain<\/option><option  value=\"Bangladesh\">Bangladesh<\/option><option  value=\"Barbados\">Barbados<\/option><option  value=\"Belarus\">Belarus<\/option><option  value=\"Belgium\">Belgium<\/option><option  value=\"Belize\">Belize<\/option><option  value=\"Benin\">Benin<\/option><option  value=\"Bermuda\">Bermuda<\/option><option  value=\"Bhutan\">Bhutan<\/option><option  value=\"Bolivia\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\">Botswana<\/option><option  value=\"Bouvet Island\">Bouvet Island<\/option><option  value=\"Brazil\">Brazil<\/option><option  value=\"British Indian Ocean Territory\">British Indian Ocean Territory<\/option><option  value=\"Brunei\">Brunei<\/option><option  value=\"Bulgaria\">Bulgaria<\/option><option  value=\"Burkina Faso\">Burkina Faso<\/option><option  value=\"Burundi\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\">Cambodia<\/option><option  value=\"Cameroon\">Cameroon<\/option><option  value=\"Canada\">Canada<\/option><option  value=\"Cape Verde\">Cape Verde<\/option><option  value=\"Cayman Islands\">Cayman Islands<\/option><option  value=\"Central African Republic\">Central African Republic<\/option><option  value=\"Chad\">Chad<\/option><option  value=\"Chile\">Chile<\/option><option  value=\"China\">China<\/option><option  value=\"Christmas Island\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\">Colombia<\/option><option  value=\"Comoros\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\">Cook Islands<\/option><option  value=\"Costa Rica\">Costa Rica<\/option><option  value=\"Croatia\">Croatia<\/option><option  value=\"Cuba\">Cuba<\/option><option  value=\"Curacao\">Curacao<\/option><option  value=\"Cyprus\">Cyprus<\/option><option  value=\"Czech Republic\">Czech Republic<\/option><option  value=\"Denmark\">Denmark<\/option><option  value=\"Djibouti\">Djibouti<\/option><option  value=\"Dominica\">Dominica<\/option><option  value=\"Dominican Republic\">Dominican Republic<\/option><option  value=\"East Timor\">East Timor<\/option><option  value=\"Ecuador\">Ecuador<\/option><option  value=\"Egypt\">Egypt<\/option><option  value=\"El Salvador\">El Salvador<\/option><option  value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option  value=\"Eritrea\">Eritrea<\/option><option  value=\"Estonia\">Estonia<\/option><option  value=\"Ethiopia\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\">Faroe Islands<\/option><option  value=\"Fiji\">Fiji<\/option><option  value=\"Finland\">Finland<\/option><option  value=\"France\">France<\/option><option  value=\"French Guiana\">French Guiana<\/option><option  value=\"French Polynesia\">French Polynesia<\/option><option  value=\"French Southern Territories\">French Southern Territories<\/option><option  value=\"Gabon\">Gabon<\/option><option  value=\"Gambia\">Gambia<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Germany\">Germany<\/option><option  value=\"Ghana\">Ghana<\/option><option  value=\"Gibraltar\">Gibraltar<\/option><option  value=\"Greece\">Greece<\/option><option  value=\"Greenland\">Greenland<\/option><option  value=\"Grenada\">Grenada<\/option><option  value=\"Guadeloupe\">Guadeloupe<\/option><option  value=\"Guam\">Guam<\/option><option  value=\"Guatemala\">Guatemala<\/option><option  value=\"Guernsey\">Guernsey<\/option><option  value=\"Guinea\">Guinea<\/option><option  value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option  value=\"Guyana\">Guyana<\/option><option  value=\"Haiti\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\">Honduras<\/option><option  value=\"Hong Kong\">Hong Kong<\/option><option  value=\"Hungary\">Hungary<\/option><option  value=\"Iceland\">Iceland<\/option><option  value=\"India\">India<\/option><option  value=\"Indonesia\">Indonesia<\/option><option  value=\"Iran\">Iran<\/option><option  value=\"Iraq\">Iraq<\/option><option  value=\"Ireland\">Ireland<\/option><option  value=\"Isle of Man\">Isle of Man<\/option><option  value=\"Israel\">Israel<\/option><option  value=\"Italy\">Italy<\/option><option  value=\"Jamaica\">Jamaica<\/option><option  value=\"Japan\">Japan<\/option><option  value=\"Jersey\">Jersey<\/option><option  value=\"Jordan\">Jordan<\/option><option  value=\"Kazakhstan\">Kazakhstan<\/option><option  value=\"Kenya\">Kenya<\/option><option  value=\"Kiribati\">Kiribati<\/option><option  value=\"Kosovo\">Kosovo<\/option><option  value=\"Kuwait\">Kuwait<\/option><option  value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option  value=\"Laos\">Laos<\/option><option  value=\"Latvia\">Latvia<\/option><option  value=\"Lebanon\">Lebanon<\/option><option  value=\"Lesotho\">Lesotho<\/option><option  value=\"Liberia\">Liberia<\/option><option  value=\"Libya\">Libya<\/option><option  value=\"Liechtenstein\">Liechtenstein<\/option><option  value=\"Lithuania\">Lithuania<\/option><option  value=\"Luxembourg\">Luxembourg<\/option><option  value=\"Macao\">Macao<\/option><option  value=\"Macedonia\">Macedonia<\/option><option  value=\"Madagascar\">Madagascar<\/option><option  value=\"Malawi\">Malawi<\/option><option  value=\"Malaysia\">Malaysia<\/option><option  value=\"Maldives\">Maldives<\/option><option  value=\"Mali\">Mali<\/option><option  value=\"Malta\">Malta<\/option><option  value=\"Marshall Islands\">Marshall Islands<\/option><option  value=\"Martinique\">Martinique<\/option><option  value=\"Mauritania\">Mauritania<\/option><option  value=\"Mauritius\">Mauritius<\/option><option  value=\"Mayotte\">Mayotte<\/option><option  value=\"Mexico\">Mexico<\/option><option  value=\"Micronesia\">Micronesia<\/option><option  value=\"Moldova\">Moldova<\/option><option  value=\"Monaco\">Monaco<\/option><option  value=\"Mongolia\">Mongolia<\/option><option  value=\"Montenegro\">Montenegro<\/option><option  value=\"Montserrat\">Montserrat<\/option><option  value=\"Morocco\">Morocco<\/option><option  value=\"Mozambique\">Mozambique<\/option><option  value=\"Myanmar\">Myanmar<\/option><option  value=\"Namibia\">Namibia<\/option><option  value=\"Nauru\">Nauru<\/option><option  value=\"Nepal\">Nepal<\/option><option  value=\"Netherlands\">Netherlands<\/option><option  value=\"New Caledonia\">New Caledonia<\/option><option  value=\"New Zealand\">New Zealand<\/option><option  value=\"Nicaragua\">Nicaragua<\/option><option  value=\"Niger\">Niger<\/option><option  value=\"Nigeria\">Nigeria<\/option><option  value=\"Niue\">Niue<\/option><option  value=\"Norfolk Island\">Norfolk Island<\/option><option  value=\"North Korea\">North Korea<\/option><option  value=\"Northern Mariana Islands\">Northern Mariana Islands<\/option><option  value=\"Norway\">Norway<\/option><option  value=\"Oman\">Oman<\/option><option  value=\"Pakistan\">Pakistan<\/option><option  value=\"Palau\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\">Panama<\/option><option  value=\"Papua New Guinea\">Papua New Guinea<\/option><option  value=\"Paraguay\">Paraguay<\/option><option  value=\"Peru\">Peru<\/option><option  value=\"Philippines\">Philippines<\/option><option  value=\"Pitcairn\">Pitcairn<\/option><option  value=\"Poland\">Poland<\/option><option  value=\"Portugal\">Portugal<\/option><option  value=\"Puerto Rico\">Puerto Rico<\/option><option  value=\"Qatar\">Qatar<\/option><option  value=\"Reunion\">Reunion<\/option><option  value=\"Romania\">Romania<\/option><option  value=\"Russia\">Russia<\/option><option  value=\"Rwanda\">Rwanda<\/option><option  value=\"Saint Barthelemy\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\">Samoa<\/option><option  value=\"San Marino\">San Marino<\/option><option  value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\">Saudi Arabia<\/option><option  value=\"Senegal\">Senegal<\/option><option  value=\"Serbia\">Serbia<\/option><option  value=\"Seychelles\">Seychelles<\/option><option  value=\"Sierra Leone\">Sierra Leone<\/option><option  value=\"Singapore\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\">Slovakia<\/option><option  value=\"Slovenia\">Slovenia<\/option><option  value=\"Solomon Islands\">Solomon Islands<\/option><option  value=\"Somalia\">Somalia<\/option><option  value=\"South Africa\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\">South Korea<\/option><option  value=\"South Sudan\">South Sudan<\/option><option  value=\"Spain\">Spain<\/option><option  value=\"Sri Lanka\">Sri Lanka<\/option><option  value=\"Sudan\">Sudan<\/option><option  value=\"Suriname\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\">Swaziland<\/option><option  value=\"Sweden\">Sweden<\/option><option  value=\"Switzerland\">Switzerland<\/option><option  value=\"Syria\">Syria<\/option><option  value=\"Taiwan\">Taiwan<\/option><option  value=\"Tajikistan\">Tajikistan<\/option><option  value=\"Tanzania\">Tanzania<\/option><option  value=\"Thailand\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\">Togo<\/option><option  value=\"Tokelau\">Tokelau<\/option><option  value=\"Tonga\">Tonga<\/option><option  value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option  value=\"Tunisia\">Tunisia<\/option><option  value=\"Turkey\">Turkey<\/option><option  value=\"Turkmenistan\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\">Tuvalu<\/option><option  value=\"Uganda\">Uganda<\/option><option  value=\"Ukraine\">Ukraine<\/option><option  value=\"United Arab Emirates\">United Arab Emirates<\/option><option  value=\"United Kingdom\" selected='selected'>United Kingdom<\/option><option  value=\"United States\">United States<\/option><option  value=\"United States Minor Outlying Islands\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\">Uruguay<\/option><option  value=\"Uzbekistan\">Uzbekistan<\/option><option  value=\"Vanuatu\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\">Venezuela<\/option><option  value=\"Vietnam\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\">Wallis and Futuna<\/option><option  value=\"Western Sahara\">Western Sahara<\/option><option  value=\"Yemen\">Yemen<\/option><option  value=\"Zambia\">Zambia<\/option><option  value=\"Zimbabwe\">Zimbabwe<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_549_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_9gu1j\" class=\"frm_primary_label\">NHS Number\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_9gu1j\" name=\"item_meta[549]\" value=\"\"  data-sectionid=\"542\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_550_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <label for=\"field_ugrnr\" class=\"frm_primary_label\">Are you completing this form on behalf of another person or child?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_550-542-0\"><label for=\"field_ugrnr-0\">\t\t<input type=\"radio\" name=\"item_meta[550]\" id=\"field_ugrnr-0\" value=\"Yes\"\n\t\t   data-sectionid=\"542\" data-reqmsg=\"Are you completing this form on behalf of another person or child? cannot be blank.\" data-invmsg=\"Are you completing this form on behalf of another person or child? is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_550-542-1\"><label for=\"field_ugrnr-1\">\t\t<input type=\"radio\" name=\"item_meta[550]\" id=\"field_ugrnr-1\" value=\"No\"\n\t\t   data-sectionid=\"542\" data-reqmsg=\"Are you completing this form on behalf of another person or child? cannot be blank.\" data-invmsg=\"Are you completing this form on behalf of another person or child? is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_552_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Section B &#8211; Complete this section of you are completing the form on behalf of another person or child<\/h3>\r\n\r\n\r\n<div id=\"frm_field_553_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_dfngu\" class=\"frm_primary_label\">Your full name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_dfngu\" name=\"item_meta[553]\" value=\"\"  data-sectionid=\"552\" data-reqmsg=\"Your full name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_554_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_4pcx4\" class=\"frm_primary_label\">Relationship to patient\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_4pcx4\" name=\"item_meta[554]\" value=\"\"  data-sectionid=\"552\" data-reqmsg=\"Relationship to patient cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_556_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Signature<\/h3>\r\n\r\n\r\n<div id=\"frm_field_557_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_942kw\" class=\"frm_primary_label\">Your Signature\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id='sigPad557' style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:150px;border-color:#cccccc;--bg-color:#ffffff;--active:#0391c6;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px\">\n\n\t\t<ul class=\"sigNav\">\n\t\t\t\t<li class=\"drawIt\">\n\t\t\t\t\t<a href=\"#\" class=\"frm-active-sig-type\" title=\"Draw It\" aria-label=\"Draw It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>signature<\/title>\n\t<path d=\"M19.7 2.2A3.5 3.5 0 0 0 14 1.1L1.7 13.4a1 1 0 0 0-.3.4l-1.3 5a.9.9 0 0 0 0 .5 1 1 0 0 0 1 .6l5-1.3c.2 0 .4-.1.5-.3L18.9 6a3.5 3.5 0 0 0 .7-3.8zm-6.8 2.6L15.2 7l-8.6 8.7-2.4-2.4zm-10.7 13l1-3.3L5.4 17zM18 4.2l-.4.5L16.3 6 14 3.7l1.3-1.3A1.7 1.7 0 0 1 18 3.6l-.1.6zM9 17.9h11v1H9v-1z\"><\/path>\n\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t\t\t<li class=\"typeIt\">\n\t\t\t\t\t<a href=\"#\" class=\"\" title=\"Type It\" aria-label=\"Type It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>keyboard<\/title>\n\t<path d=\"M20.6 2.5H2c-1 0-1.9.8-1.9 1.9v11.2c0 1 .8 1.9 1.9 1.9h18.7c1 0 1.9-.8 1.9-1.9V4.4c0-1-.8-1.9-1.9-1.9zm.3 13.1c0 .2-.1.3-.3.3H2a.3.3 0 0 1-.3-.3V4.4c0-.2.1-.3.3-.3h18.7c.2 0 .3.1.3.3v11.2zm-14.3-5V9.4c0-.3-.2-.5-.4-.5H5c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5H9c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5H10c.3 0 .5-.2.5-.5zm3.7 0V9.4c0-.3-.2-.5-.4-.5h-1.1c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5h1.1c.3 0 .5-.2.5-.5zM4.8 7.2v-1c0-.3-.2-.5-.5-.5H3.2c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm3.7 0v-1c0-.3-.2-.5-.5-.5H7c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0v-1c0-.3-.2-.5-.5-.5h-1.1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm3.7 0v-1c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0v-1c0-.3-.2-.5-.5-.5h-1.1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm-2 6.2V13c0-.3-.2-.5-.6-.5h-12c-.3 0-.6.2-.6.5v.6c0 .3.3.5.7.5h12c.3 0 .6-.2.6-.5z\"><\/path>\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t<\/ul>\n\n\t\t<span class=\"frm-typed-drawline\"><\/span>\n\n\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[557][typed]\" class=\"name\" id=\"field_942kw\" autocomplete=\"off\" value=\"\"  data-sectionid=\"556\" style=\"width:400px\" maxlength=\"150\" data-reqmsg=\"We need your signature to proceed.\" aria-required=\"true\" class=\"auto_width\" aria-invalid=\"false\"   \/>\n\t\t<\/div>\n\n\t\t<canvas class=\"pad\" data-fieldid=\"557\" data-fieldname=\"item_meta[557]\" width=\"396\" height=\"150\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\n\t\t<input type=\"hidden\" name=\"item_meta[557][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    <div class=\"frm_description\" id=\"frm_desc_field_942kw\">Please sign your name to confirm. You may draw with mouse, stylus, touch or select the &#8220;Type It&#8221; option to type your signature.<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_558_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_4mfkh\" class=\"frm_primary_label\">Date of signature\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_4mfkh\" name=\"item_meta[558]\" value=\"05\/13\/2024\"  readonly=\"readonly\"  data-sectionid=\"556\" data-frmval=\"05\/13\/2024\" data-invmsg=\"Date of signature is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_4mfkh\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_4mfkh\">Today&#8217;s date is automatically inserted here.<\/div>\r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_560_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Privacy Policy<\/h3>\r\n\r\n\r\n<div id=\"frm_field_561_container\" class=\"frm_form_field  frm_html_container form-field\">This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our <a href=\"\/about-us\/practice-policies\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a> to discover how we protect and manage your submitted data.<\/div>\n<div id=\"frm_field_562_container\" class=\"frm_form_field form-field  frm_required_field frm_inline_container vertical_radio\">\r\n    <label for=\"field_xh1m0\" class=\"frm_primary_label\"> \r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_562-560-0\"><label for=\"field_xh1m0-0\"><input type=\"checkbox\" name=\"item_meta[562][]\" id=\"field_xh1m0-0\" value=\"I consent to the practice collecting and storing my data from this form.\"  data-sectionid=\"560\" data-reqmsg=\"We need your consent to proceed. Please tick the box to consent.\" data-invmsg=\"  is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> I consent to the practice collecting and storing my data from this form.<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_1069_container\" class=\"frm_form_field form-field  frm_none_container\">\r\n    <label for=\"g-recaptcha-response\" id=\"field_ppinw_label\" class=\"frm_primary_label\">reCAPTCHA\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div  id=\"field_ppinw\" class=\"g-recaptcha\" data-sitekey=\"6Lcd8fwcAAAAAIM2qaOLbiAQ3VO_gpszfg2tmOno\" data-size=\"normal\" data-theme=\"light\"><\/div>\r\n    \r\n    \r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t\t<div class=\"frm__654fbadf5067e\">\n\t\t\t\t<label for=\"frm_email_25\" >\n\t\t\t\t\tIf you are human, leave this field blank.\t\t\t\t<\/label>\n\t\t\t\t<input  id=\"frm_email_25\" type=\"text\" class=\"frm_verify\" name=\"frm__654fbadf5067e\" value=\"\" autocomplete=\"false\"  \/>\n\t\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"ytt8me3z\/ppVmsQc7n0lJ8oK83mVDtsAjl0T6O8xYFU=\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Send<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<\/form>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":6577921,"featured_media":2358,"parent":94,"menu_order":3,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","_uag_custom_page_level_css":"","advgb_blocks_editor_width":"","advgb_blocks_columns_visual_guide":"","footnotes":"","_links_to":"","_links_to_target":""},"acf":[],"uagb_featured_image_src":{"full":["https:\/\/www.drpolding.scot.nhs.uk\/wp-content\/uploads\/2019\/02\/adult-business-communication-1181722.jpg",2048,1365,false],"thumbnail":["https:\/\/www.drpolding.scot.nhs.uk\/wp-content\/uploads\/2019\/02\/adult-business-communication-1181722-150x150.jpg",150,150,true],"medium":["https:\/\/www.drpolding.scot.nhs.uk\/wp-content\/uploads\/2019\/02\/adult-business-communication-1181722-300x200.jpg",300,200,true],"medium_large":["https:\/\/www.drpolding.scot.nhs.uk\/wp-content\/uploads\/2019\/02\/adult-business-communication-1181722-768x512.jpg",768,512,true],"large":["https:\/\/www.drpolding.scot.nhs.uk\/wp-content\/uploads\/2019\/02\/adult-business-communication-1181722-1024x683.jpg",1024,683,true],"1536x1536":["https:\/\/www.drpolding.scot.nhs.uk\/wp-content\/uploads\/2019\/02\/adult-business-communication-1181722.jpg",1536,1024,false],"2048x2048":["https:\/\/www.drpolding.scot.nhs.uk\/wp-content\/uploads\/2019\/02\/adult-business-communication-1181722.jpg",2048,1365,false]},"uagb_author_info":{"display_name":"Editor","author_link":"https:\/\/www.drpolding.scot.nhs.uk\/author\/gary-genpra\/"},"uagb_comment_info":0,"uagb_excerpt":null,"coauthors":[],"author_meta":{"author_link":"https:\/\/www.drpolding.scot.nhs.uk\/author\/gary-genpra\/","display_name":"Editor"},"relative_dates":{"created":"Posted 6 years ago","modified":"Updated 5 years ago"},"absolute_dates":{"created":"Posted on 2nd May 2018","modified":"Updated on 9th February 2019"},"absolute_dates_time":{"created":"Posted on 2nd May 2018 8:10 pm","modified":"Updated on 9th February 2019 10:48 am"},"featured_img_caption":"","featured_img":"https:\/\/www.drpolding.scot.nhs.uk\/wp-content\/uploads\/2019\/02\/adult-business-communication-1181722.jpg","series_order":"","publishpress_future_action":{"enabled":false,"date":"2024-05-20 00:31:12","action":"change-status","newStatus":"draft","terms":[],"taxonomy":""},"_links":{"self":[{"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/pages\/1379"}],"collection":[{"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/users\/6577921"}],"replies":[{"embeddable":true,"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/comments?post=1379"}],"version-history":[{"count":0,"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/pages\/1379\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/pages\/94"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/media\/2358"}],"wp:attachment":[{"href":"https:\/\/www.drpolding.scot.nhs.uk\/wp-json\/wp\/v2\/media?parent=1379"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}