Subject Access Request

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Medical Records

Full Name *

Date of Birth *

Email *

Mobile Phone Number *

Full Address *

Previous Address

Request Details

Please describe the information you require together with any other relevant information eg date of operation/procedure, type of appointment, the consultant you saw etc. *

How would you like to receive the data?

Please tick at least one I would like photocopies sent recorded delivery: I would like to attend to collect the original record: I would like an email sent securely:

Request for Images

Please tick, if you require any images to support your request.

Please tick all that apply The images are for my own personal use The images are for an appointment I am going to The Images are part of a medical legal proceedings

Images Required

Please Note:
I understand I will receive an email within 5 working days containing a download link for the images, and a password will be sent once the link is accessed.
Images and viewing software will be downloaded to my PC or MAC.
I have 60 days from the email date to download the images; if not, additional fees apply for resending. Once downloaded, I am responsible for the images.

Collecting the Copies in Person

When collecting copies in person you will be required to provide proof of identification, such as driving licence, passport or recent utility bill.

If you have consented to having another person collect on your behalf, please give the name below and in what capacity they have been given your authorisation/ consent. The nominated person collecting your record will need to provide identification as mentioned above.

Nominated person’s and/or Organisation’s name:

Relationship

Full Address

By checking this box, I confirm that I have read and understood the above information. *