Access to Medical Record Request Access to Medical Record Consent Patient DetailsSurname First Name Date of Birth Day Month Year Gender Male Female Address Street Address Address Line 2 City Postcode Main Contact TelephoneEmail Address Would you like your records emailing to you? Yes No Please make a selection of your request: A full copy of my medical records including paper records The past 5 years of computerised records Records from a specific date Other Other: Please Specify Date from: Day Month Year Date to: Day Month Year I Understand that my request may take up to 30 days to be processed Yes Would you like to give consent to have someone on your behalf collect your records? Yes No Not applicable Full name of person collecting records I consent to have my records collected by the given name above Yes I Consent DUE TO CONFIDENTIALITY, I UNDERSTAND THAT I WILL BE ASKED TO PRODUCE PHOTO I.D. WHEN COLLECTING MY RECORDS. Yes I Consent As you have chosen to recieve your records via email please upload a copy of your photo identification for data security. Drop files here or Select files Max. file size: 50 MB. If you are requesting records on behalf of a child and the child is not able to give consent for him/herself, someone with parental responsibility should do so on his/her behalf. I am the Patient I am the Parent I am the Guardian Your Full Name