Access to Health Records

 

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Applicant Details
Please included any former names we would have known you by
Please double check you've entered the correct email address
May be used to identify you
Patient Details (if different from above)
 
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Additional Information

In order to process your request we require you to provide the following:

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Declaration

You are advised that the 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.

Please tick as appropriate:

 
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Evidence

Evidence of the patient’s and/or the patient’s representative identity will be required. Please attach copies of the required documentation to this application form. Examples of required documentation are:

  Type of applicant Type of documentation
A An individual applying for his/her own records One copy of identity required, e.g. copy of birth certificate, passport, driving licence, plus one copy of a utility bill or medical card, etc.
B Someone applying on behalf of an individual (Representative) One item showing proof of the patient’s identity and one item showing proof of the representative’s identity (see examples in ‘A’ above)
C Person with parental responsibility applying on behalf of a child Copy of birth certificate of child & copy of correspondence addressed to person with parental responsibility relating to the patient
D Power of Attorney/Agent applying on behalf of an individual Copy of a court order authorising Power of Attorney/Agent plus proof of the patient’s identity (see examples in ‘A’ above)
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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