Patient Record Access Request Form

You have a right to receive a copy of the data/information we hold about you or to authorise someone to act on your behalf. Please complete this form and provide proof of your identity. Your request will be processed within 30 calendar days on receipt of a fully completed request form with proof of identity.

Proof of identity: We require proof of your identity before we can disclose your personal data. Proof of your identity should include a copy of two documents listed below :

  • Your birth certificate,
  • Passport,
  • Driving licence,
  • An official letter dated not older than 90 days to you at your address e.g. bank statement, recent utility bill or council tax bill.

The documents should include your name, date of birth and current address. If you have changed your name, please supply relevant documents evidencing the change. No administration charge is applicable for your first request.

Patient Record Access Request Form
Please advise if this is for the BCOM Clinic or ESO Clinic

Personal Details

Are you completing this form on behalf of someone else?

Only complete your details in this section if the request is on behalf of someone else

Maximum file size: 20MB

Your proof of authority can include a letter of authority, a copy of Lasting or Enduring Power of Attorney, evidence of parental responsibility or other formal information.

Proof of Identity

Maximum file size: 10MB

Data Subject’s Declaration

I certify that the information provided on this form is correct to the best of my knowledge and that I am the person to whom it relates. I understand that you are obliged to confirm proof of identity/authority and it may be necessary to obtain further information in order to comply with this subject access request.

On behalf of the Data Subject

I confirm that I am legally authorised to act on behalf of the data subject. I understand that you are obliged to confirm proof of identity/authority and it may be necessary to obtain further information in order to comply with this subject request.

Personal Information Request

Warning: Anyone who unlawfully obtains or attempts to obtain data is guilty of a criminal offence and is liable to prosecution.

Data Format

Please select your preference for receiving the information
* Please be aware that if information is emailed, we will send it as a password protected PDF file, with the password sent in a separate email.
** Please be aware that if information is posted, we will take every care to ensure that it is addressed correctly.
However, we cannot be held liable if the information is lost in the post or incorrectly delivered or opened by someone else in your household. Loss or incorrect delivery may cause you embarrassment or harm if the information comprises of special category data.