Looking to request access to your medical records? Complete our SAR form below

Subject Access Requests, Medical Records, and Useful Information

Subject Access Request Form

Use our Subject Access Request form to request access to your medical records, personal information, and related documentation held by the practice.

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Subject Access Request (SAR)

Name

First Last

I am requesting(Required)

My own medical records

The medical records of another adult

The medical records of a child

Please note if you are not the patient, and you have the permission of a third party to act on their behalf, then both persons must be present when completing this online form. We will require them to complete “The Authorisation of Patient if Request made by Third Party” declaration shown below. This section will appear when the relevant consent box is ticked at the end of the online form. If this section is not completed, we cannot process the subject access request.

Date of birth

DD slash MM slash YYYY

Preferred Phone number

The Medical Records of another Adult

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of birth

MM slash DD slash YYYY

This field is hidden when viewing the form

Section Break

The Medical Records of a Child

Name of child

First Last

Address of child

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of birth of child

MM slash DD slash YYYY

This field is hidden when viewing the form

Section Break

Type of Request

Copy of Parts of Medical Records

Partial Medical Records

Full Medical Records

Other

Please detail which parts you require

Results

Immunisation Summary

Referral Letter(s)

Clinic Letter(s)

Other (please specify below)

Please specify

Date Range of medical records required:

Please specify

Consent

I am the Patient

I have been asked to act by the patient as detailed and who has signed the authorisation section

I am the parent/guardian of a patient who is between the age of 12 years old and 16 years old who has signed the authorisation section

I am the parent/guardian of a patient who is under 12 years old who is unable to understand the request

Signature of Applicant

Signature of Patient

I authorise the Practice to release Personal Data requested relating to me to the above applicant to whom I have given my consent to act on my behalf.

Proof of Identification

Max. file size: 128 MB.

Please upload proof of your idenfication to allow us to process your request

I consent to the practice collecting and storing my data from this form.

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Comments

any further information you would like to give on what is required?

"When you call the surgery, you’ll be asked briefly about your enquiry so you can be directed to the most suitable service or healthcare professional, rather than automatically booking with a GP."

Mrs Louisa Munro

Practice Manager

Looking to request access to your medical records? Complete our SAR form below

Subject Access Requests, Medical Records, and Useful Information

Subject Access Request Form

Subject Access Request (SAR)

The Medical Records of another Adult

Section Break

The Medical Records of a Child

Section Break

"When you call the surgery, you’ll be asked briefly about your enquiry so you can be directed to the most suitable service or healthcare professional, rather than automatically booking with a GP."

Mrs Louisa Munro

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