Access to health records form – The Lakes Medical Practice

Section 1: Details of the individual for whom the request relates

First name (s)(Required)

Surname(Required)

NHS number(Required)

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Your address (including postcode)(Required)

Contact number(Required)

Section 2: Whose personal data are you requesting?

Information about you

If you are not requesting access to your own personal data, please provide the following information

First name(s)(Required)

Surname(Required)

Your address (including postcode)(Required)

Contact number(Required)

Relationship to individual for whom you are requesting data(Required)

Section 3: What data are you requesting?

Please provide as much detail as possible as to the data you are requesting, or actions relating to restriction, erasure, rectification, or objection. Please be as specific as possible as this will speed up the request process, include time periods and specific episodes of illness or treatment wherever possible.(Required)

Signature

Please enter your full name below(Required)