Medical report request

If you would like to request a medical report, please use this form.

Application for access to medical records (SAR)

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

Section 1: Patient details

If you are applying to view your own records, please go to Section 2. 

If you are applying to view another person’s record, please go to Section 3. 

Section 2: Record requested

Please tick the relevant boxes below. The more specific you can be, the easier it is for us to quickly provide you with the records requested. Record in respect of treatment for: (e.g., leg injury following a car accident)
Please specify what information you are requesting:
Write your full name to sign this application

Section 3: Details and Declaration of Applicant

Please complete if you are requesting access on behalf of the above-named patient

If more than one person is to be given access then please list the above details for each additional person below

Choose a relevant option
Please specify what information you are requesting:
Reason for access:


I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the UK Data Protection Act 2018.

You are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution.

Write the full name of the applicant to sign the declaration

I confirm that I give permission for the organisation to communicate with the person identified above regarding my medical records 

For patients: write your full name to confirm that you give permission for the organisation to communicate with the person identified above regarding your medical records

Section 4: Proof of identity 

Under the Data Protection Act 2018 you do not have to give a reason for applying for access to your health records.  

Patients with capacity and proxy nominees will be asked to provide two forms of identification one of which must be photographic identification. Please speak to reception if you are unable to provide this.  

Section 5: Consent for children 

If a child aged 13 or over has “sufficient understanding and intelligence to enable him/her to understand fully what is proposed” (known as Gillick Competence), then s/he will be competent to give consent for him/herself.   

They may wish a parent to countersign as well.  

Young people aged 16 and 17 are legally competent and may therefore sign this consent form for themselves but may wish a parent to countersign as well.  

If the child is under 18 and not able to give consent for him/herself, someone with parental responsibility may do so on his/her behalf by signing this form below. 

Tick the box to give consent if you are the patient aged 13 – 18 years

For the parent/guardian/person with parental responsibility: complete the fields below

Write your full name to sign the document

Before returning this form, please ensure that you: 

  • Have signed and dated the form 
  • Are able to provide proof of your identity or alternatively confirmed your identity by a countersignature 
  • Enclosed documentation to support your request (if applicable) 

Incomplete applications will be returned; therefore, please ensure you have the correct documentation before returning the form. 

Identification verification must be verified through 2 forms of ID 

  • One of which must contain a photo e.g., passport, photo driving licence or bank statement.   

Where this is not available, vouching by a member of staff or by confirmation of information in the records by one of the clinicians may be used. 

If this is a proxy request, where patient has capacity, both patient and proxy should provide identification as above in person.