Medical Report and Access to Records Requests

If you would like to request a medical report or access to records, please use this form.

Medical Report and Access to Records Requests

Medical Report and Access to Records Requests

Please enter the patient's details below:
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please select the service/s you require: *

Medical Reports

What type of medical report would you like?

Access to Records

Are details of the applicant different to the patient's details above? *
Please be aware that if we need to respond, we may reply using the email address listed within the patient's details section.
Please include a postcode

Details of Record to be Accessed

Records dated MM/YYYY
Records dated MM/YYYY
Please select one of the following options that best describes your application: *

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 the health record(s) referred to above, under the terms of the Access to Health Records Act (1990) / Data Protection Act (2018).

I also understand that I am now the controller of the records provided to me and should I need further copies from the practice, there will be a fee for this.

Please write full name
Please write DD/MM/YYYY
Please note:

If you are making an application on the behalf of somebody else, we require evidence of your authority to do so, i.e personal authority, court order etc.

It may be necessary to provide evidence of identity, i.e Driving Licence etc.

If there if any doubt about the applicant's identity or entitlement, information will not be released until further evidence is provided. You will be informed if this is the case.