Access to Health Records

Address: *

What is your preferred format to receive your records? *

Electronic: Via a secure NHS mail account

Paper: To be collected directly from the surgery

Please confirm the email address records should be sent to: *

Records Requested

Please choose one of the following options: *

Summary care records

A printout of a letter or results from your record

Full medical records

Department/Letter type: *

Date of letter/results: *

Declaration

I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to my/the patient's health records referred to above under the terms of GDPR.

This includes under full parental responsibility that you confirm the patient has either consented to making this request, or is incapable of understanding the request.

If applying for someone else's records, the written consent needs to be within the last three months.

Please confirm: *

I am the patient

I have been asked to act by the patient and attach the patient's written authorisation

I have full parental responsibility for the patient and the patient is under the age of 18

I have been appointed by the court to manage these patients' affairs and attach a certified copy of the court order appointing me to do so

Please indicate: *

Patient consented to making the request

Patient is incapable of understanding the request

Signature: *

Enter full name

Date:

Upload a photograph or document:

Drop a file here or click to upload Choose File

Maximum upload size: 67.11MB

You are advised that making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution.

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