Online Access to Health Records Request

In accordance with the UK General Data Protection Regulation (UK GFPR)

This field is for validation purposes and should be left unchanged.
Name
Address
I wish to have access to the following online services (please tick all that apply)
I wish to access my medical record online and both understand and agree with each of the follow statements (please tick):
DD slash MM slash YYYY

Proof of Identity

Under the Data Protection Act 2018, you do not have to give reason for applying for access to your own health records. However, all applicants will be asked to provide two forms of identification, one of which must be photographic identification before access can be set up.

Incomplete applications will be returned; therefore, please ensure you have signed the form and can provide two forms of identification.

IDENTIFICATION EXAMPLES:

– PASSPORT (PHOTO)

– DRIVING LICENSE (PHOTO)

– BRITH CERTIFICATE

– NATIONAL INSURANCE CARD

– BLUE BADGE

– UTILITY BILL

– BANK STATEMENT

Drop files here or
Max. file size: 1 GB.

    Verification

    DD slash MM slash YYYY
    Identification method: