Access to Medical Records

If you would like access to your medical records please complete and submit this form; to verify your request you will need to provide proof of ID (photo ID) by visiting the practice.

Subject Access Request Form

Patient Details

Patient Name

First Last

Contact Number

Telephone

Patient Date of Birth

Patient Address

Street Address Address Line 2 City Postcode

Proof of Identity

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB, Max. files: 2.

Please submit: 1. Proof of ID, 2. A utility bill dated within 3 months. We cannot process the request without both documents being uploaded.

Request Details

What would you like to request?

Please specify the nature of your request

Test Results Request (Specific Time)

Use the boxes below to specify the period of time you would like to request your test results from.

Opening Date

Closing Date

Medical Records Request (Specific Time)

Use the boxes below to specify the period of time you would like to request your medical records from.

Opening Date

Closing Date

Document Collection

Who will be collecting your documents?

Someone Else

If you are choosing a person to collect documents on your behalf, please note that once handed over we can no longer guarantee that your information will not be intercepted by a third party.

Full Name

First Last

Please enter the full name of the third party collecting your documents

Date of Birth

Please enter the date of birth of the third party collecting your documents

In Closing

Signature

Please PRINT your full name

Please input today's date

Name Optional

This field is for validation purposes and should be left unchanged.