Subject Access Request Form

Please use this form to request copies of medical records for reports, PPI requests etc. Your contact details are important as we may be need to get in touch to verify the information and format required.

Please note that to meet Data Protection guidance you may be asked to provide identification prior to release of any medical records.

As per national guidance there is no charge for a first copy of medical records unless the request is deemed to be excessive or unreasonable. This is unfunded NHS work therefore subsequent requests may incur a charge up to maximum of £50.

We have 30 days to comply with requests for medical records. We will contact you if, for reasons beyond our control, your request cannot be completed in this time frame or if you have requested a more urgent response.

Last Updated: 01/12/2022

Your name

What is your name? *

Date of Birth

Date of birth *

What telephone number would you like us to contact on?

Phone Number *

What information do you need?

Please request the specific information you need.

Which part of your record are you requesting. Please tick below *

Immunisation History

Medications List

Medical problems

Information relating to a specific condition (please specify below)

All records within a timeframe

All records

Please use this section to specify a time frame or condition requested

Add information here *

Subject Access Request Form

Further Information