Access to Medical Records Access to Medical Records Applicant DetailsFull NamePlease included any former names we would have known you byDate of Birth DD slash MM slash YYYY Email Address Please double check you’ve entered the correct email addressPhone NumberSecurity Question (used to identify you):In which month did you last see a doctor/nurse at this practice?Do you take any prescribed medication? Can you tell me what they are?Have you had an operation in hospital? Can you remember when and what for?May be used to identify youCurrent Postal Addressincluding postcodeWould there have been a former postal address we would have on record? Yes Optional No Optional Previous Postal Addressincluding postcodeDependantsAre you applying on behalf of any under 16 year olds? Yes No Dependant 1Name First Last Date of Birth DD slash MM slash YYYY Your relationship with the dependantDo you need to add another? Yes No Dependant 2Name First Last Date of Birth DD slash MM slash YYYY Your relationship with the dependantDo you need to add another? Yes No Dependant 3Name First Last Date of Birth DD slash MM slash YYYY Your relationship with the dependantDo you need to add another? Yes No Dependant 4Name First Last Date of Birth DD slash MM slash YYYY Your relationship with the dependantAdditional InformationUnder the Data Protection Act you do not have to provide a reason for applying for access to health records. However to help us save time and resources, it would be helpful if you could provide details informing us of periods and parts of the health records you require access to, along with details which you may feel are relevant: OptionalPhoto proof of your address. e.g. Bank statement, Utility Bill, Tenancy Agreement or Mobile Phone BillMax. file size: 1 GB. Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptxPhoto proof of ID e.g. Passport or Driving LicenceMax. file size: 1 GB. Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptxDeclarationConsent I confirm that I have parental responsibility for any dependants listed as aboveConsent I confirm that as the applicant I am over 16 years oldI declare that the information provided is correct and can be used appropriately to provide access to my Healthcare RecordsPrivacy Consent I consent to the practice collecting and storing my data from this form. OptionalThis form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.