Section 1: Details of person whose records are being requested
Applicant Details (if making a request on behalf of the person above)
Section 3: Further Information

Please try and tell us what specific information you wish to see and provide as many details as possible so that we can identify your records as quickly as possible e.g., dates, department, location.

Section 4: Consent

Please tick one of following boxes and submit below:

Note: Evidence

Evidence of the patients and/or the patient’s representative identity will be required; this will require two items of documentation (one of which should contain a photograph)

I am applying to access my health records under the Data Protection Act 2018/Access to Health Records Act 1990.

I understand that under this legislation, there may be a charge for me to view, or to be provided with, a copy of the health records identified.