Application for Access to Medical Records

(Data Protection Act 1998 and General Data Protection Regulation Subject Access Request)

Details of the Record to be accessed:

Please complete all sections below. Please note that if you are requesting access to medical records that are not your own (unless you are requesting them for your dependent under the age of 11) you will need to collect paper forms from our reception.

Full Name (Forenames and Surname) for the record to be accessed *

Date Of Birth for the record to be accessed *

Your Full name and relationship to patient (Forenames and surname) if different to the above

Phone number *

email address *

Current Address *

Medical record request

Please state the extent of your information request.

Please note all requests can take between 14-30 working days.

Once completed you will receive a text to inform you that the records are ready and details of how you are able to receive them.

If you have already requested a full set of notes from us, we may we charge £50 for each subsequent copy of full notes requested for the same patient. We accept cash or card payments.

IF COLLECTING RECORDS FROM OUR RECEPTION DESK, YOU WILL BE REQUIRED TO BRING PHOTO ID.

I understand that this form collects my name, and any other personal information that I choose to provide. This is to confirm I am registered with the practice; to allow the practice team to contact me and to update the medical records held by them and their partners in the NHS. I understand that I am able to read the privacy policy (Located at the footer of the website) to discover how they protect and manage my submitted data. *

I consent to the practice collecting and storing my data from this form and understand that anything not relating to this form will not be actioned

Please complete the declaration below before submitting this form *

I declare that I am the patient or their guardian, the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health record referred to above under the terms of the Data Protection Act 1998 and the General Data Protection Regulation 2018.

A Brief Medical Summary (this can take up to 14 working days) *

Yes No

A Full Medical Summary (this can take up to 14 working days) *

Yes No

A specific document - please provide details (this can take up to 14 days)

A copy of everything relating to (please provide details of specific condition or appropriate information (this can take up to 30 working days)

Notes

Under the Data Protection Act 1998 you do not have to give a reason for applying for access to your health records.

Optional - please use this space in each section to inform us of any certain periods and parts of your health record you may require access to or provide more information.

All medical requests will be dealt with in accordance with our policies. The timescale under GDPR dictates that an inforation request must be completed within one month unless it has been extended. While we recognise that some items are urgent, all items need to be seen and approved by relevant individuals such as your registered GP.

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Page last reviewed: 24 July 2025

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