Patient Access to Medical Records – Request Form

Patient Details


What is being applied for (tick as applicable):

You do not have to give a reason for applying for access to the health records. However, to help the Practice save time and resources, it would be helpful if you could provide details below, informing us of periods and elements of the health records you require, along with details which you may feel have relevance i.e. consultant name, location, written diagnosis and reports etc.

Please tick the appropriate box: *

Representative’s Details


Please provide a copy of proof of identity.

Drag & Drop files here or click to browse

Acceptable file formats are JPG, PNG OR PDF. The combined file size should not exceed 3MB.

Fields marked with an asterisk (*) are mandatory