Access to Medical Records

Application for Access to Medical Records

Section 1: Patient details

Patient Details
Date of Birth

Section 2: Record requested

Record request

If you have ticked to view the records online only – Please fill in section 3 If you have ticked to have an electronic or printed copy of the medical records – Please fill in section 4

Section 3: Access Type

Access Type
I wish to have access to the following online services (please tick all that apply):
I wish to access the medical record online and both understand and agree with each of the following statements:

Section 4: What information you require

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 specify what information you are requesting:
Date of signing

If applicable, you will be telephoned / sent an SMS when the copies are ready for collection or posting.

Section 5: Details and Declaration of patient for proxy access

Please complete below if you are requesting access ON BEHALF OF THE ABOVE NAMED PATIENT: (If you are requesting access on behalf of someone else, please ensure you fill in Section 6)
(If more than one person is to be given access then please list the above details for each additional person in the further information section below

Section 6: Reason for access

Reason for access


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.

MM slash DD slash YYYY
I confirm that I give permission for the organisation to communicate with the person identified above regarding my medical records
MM slash DD slash YYYY

Section 7: Proof of identity

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.

Section 8: Consent for children

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 s/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.

MM slash DD slash YYYY
Relationship of signee to patient
MM slash DD slash YYYY


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.