If you are applying to view your own records, please go to Section 2.

If you are applying to view another person’s record, please go to Section 3

Please tick the relevant boxes below. The more specific you can be, the easier it is for us to quickly provide you with the records requested. Record in respect of treatment for: (e.g., leg injury following a car accident).

Please note that if you request an electronic copy of your medical record, we will aim to fulfil this request but this will not be suitable for all requests depending on the amount/size of records requested - a paper copy will be supplied in this instance.

If you are requesting an electronic copy of your records you are confirming you accept the risks of receiving the data via unencrypted means to a non-NHS email address (for example – unauthorised interception of data)

Please specify what information you are requesting:

Please complete if you are requesting access on behalf of the above-named patient. Please note we may contact the patient to verify this request.

Please specify what information you are requesting:

Reason for access

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 records referred to above under the terms of the UK Data Protection Act 2018.  

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 complete if applicable, for example patient has capacity) - I confirm that I give permission for the applicant to receive the above agreed documentation (in section 3) regarding my medical records

Under the Data Protection Act 2018 you do not have to give a reason for applying for access to your health records. Patients with capacity and proxy nominees will be asked to provide two forms of identification one of which must be photographic identification. Please speak to reception if you are unable to provide this. 

If a child aged 13 or over has “sufficient understanding and intelligence to enable him/her to understand fully what is proposed” (known as Gillick Competence), then she/he will be competent to give consent for him/herself. They may wish a parent to countersign as well. 

Young people aged 16 and 17 are legally competent and may therefore sign this consent form for themselves but may wish a parent to countersign as well. If the child is under 18 and not able to give consent for him/herself, someone with parental responsibility may do so on his/her behalf by signing this form below.

You will be notified when the copies are ready for collection or posting.

Additional Notes

Before returning this form, please ensure that you:

• Have signed and dated the form
• Are able to provide proof of your identity or alternatively confirmed your identity by a countersignature
• Enclosed documentation to support your request (if applicable)

Incomplete applications will be returned; therefore, please ensure you have the correct documentation before returning the form.

A copy of this form will be saved to the patient’s records.