Application for Access to Medical Records

If you require a patient summary or patient notes, this consent form will need to be completed in order for you to obtain any information from the notes.

Application for Access to Medical Records

Details of person who wishes to access the records

Please use date format DD/MM/YYYY
Leave blank if you are the patient.

Details of the Patient Record to be Accessed (if different from above)

Please use date format DD/MM/YYYY

Details of my Application

Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY
PLEASE NOTE: If the records are an excessive amount and repeated requests, an admin fee may be charged which is deemed reasonable by the practice. The practice will give you an indication of what this fee is prior to your request being fulfilled. Any fee is payable in cash directly to the practice. Please allow 21 days from the date we receive the request to completion. Under the Data Protection Act 1998 you do not have to give a reason for applying for access to your health records. Under the Access to Health Records Act you will need to give reasons for applying for access to a deceased person’s health records.You may be asked to provide photographic identification.

My Declaration

If you are making the request on behalf of the patient