Subject Access Request (SAR)

If you would like to make a Subject Access Request please use this form.

Last Updated: 10/11/2022

Patient Details

Full Name (All names as they appear on your birth certificate) *

Date of Birth *

Phone Number *

Email Address *

Requestor Details

If you are NOT the Patient, this section must be completed in full.

The Patient may be contacted to confirm their consent to your requesting data on their behalf.

Requestor FULL Name

Relationship to Patient

Contact Telephone Number and Email

Subject Access Request: Full Record

Please note, anything included in your record prior to 2001 will be displayed as a summary of key events and information.

If you require a full record of data prior to 2001 please provide reason in the box provided.

Request for Full Record (Please select range required)

Full Record - with summary of events prior to 2001

Full Record - within a specified date range (Detail below)

Full Record - including full record prior to 2001 (Provide reason below)

If requesting 'Full Records - within a specified date range', please state the date(s) to be included:

If requesting 'Full Record - Including full record prior to 2001', Please provide your reasons why:

Subject Access Request: Specific Events

Use this section for requesting a specific piece of information, such as records of a certain condition, a particular document, or the results of a test for example

For immunisation records, please use the NHS App

Request for records of a Specific Event

Letter or Document about me (Detail below)

Test Result (Detail below)

Other Specific Event(s) (Detail below)

For Immunisation Records (Please use NHS App)

Details of the Specific Event required (Please provide any known information, including subject and date)

Confirmation

You will be contacted to confirm your identity, this may require you to attending the surgery in person. Proof of Identity may not be required if you are registered for Online Services. *

I am a registered Online Services user

I'm NOT registered for Online Services

This form collects your name, Date of Birth, email address and other personal information. Please confirm you are registered with the Practice, you allow the Practice and medi2data to contact you and process your request. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR DATA. *

I consent to the practice collecting and storing my data from this form. I consent to medi2data processing my data on behalf of the Practice

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Subject Access Request (SAR)

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