Access To Medical Records

 

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Please complete our online form

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Applicant Details
Please included any former names we would have known you by
Please double check you've entered the correct email address
May be used to identify you
Dependants
Over 16's will have to complete their own applications

Dependant 1

Dependant 2

Dependant 3

Dependant 4

If you need to add any more, please complete an additional application

Additional Information

In order to process your request we require you to provide the following:

The Practice has 28 days to comply with your request. On completion we can make the records available for collection or we can release them via email. Please note if you request copies of all medical records, these can only be collected from the Practice.

Declaration

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.

 
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