Subject Access Request

Page {{ paginatorProps.current }} of {{ }} ({{ paginatorProps.percentage }}% completed)
Patient's Details
Please included any former names
Please double check you've entered the correct email address
Record Requested
e.g. radiology results, information relating to a specific accident
Applicant's Details
Proof of Authority

Patients with capacity and proxy nominees will be asked to provide two forms of identification one of which must be photographic identification. Please speak to reception if you are unable to provide this.

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

If there is any doubt about the applicant’s identity or entitlement, information will not be released until further evidence is provided. You will be informed if this is the case.

Under the terms of the Data Protection Act, Subject Access Requests will be responded to within one calendar month after receiving all necessary information and/or fee required to process the request.

Under the terms of Section 7 of the Data Protection Act, Information disclosed under a Subject Access Request may have information removed; this is to ensure that the confidentiality is maintained for third parties referred to who have not consented to their information being disclosed.

Please note that we will contact the patient by telephone (using the information on their records) to verify the patients request and identity

You are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution.

If a child aged 13 or over has “sufficient understanding and intelligence to enable him/her to understand fully what is proposed” (known as Gillick Competence), then s/he will be competent to give consent for him/herself and a parent may countersign. If the child is not able to give consent for him/herself, someone with parental responsibility may do so on his/her behalf by signing this form below

Privacy Consent

This 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.


There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.