Access your Medical Records (SARs) – Barclay Livingston North

Applicant Details

First Name

Last Name

I am requesting

My own medical records

The medical records of another adult

The medical records of a child

Please note if you are not the patient, and you have the permission of a third party to act on their behalf, then both persons must be present when completing this online form.

We will require them to complete “The Authorisation of Patient if Request made by Third Party” declaration shown below. This section will appear when the relevant consent box is ticked at the end of the online form.

If this section is not completed, we cannot process the subject access request.

Enter Email

Date of birth

Please use format day/month/year e.g. 12/05/1979

Preferred Phone number

The Medical Records of another Adult

Name of adult

Address of adult

Please include postcode

Date of birth of adult

Please use format day/month/year e.g. 12/05/1979

The Medical Records of a Child

Name of child

Address of child

Please include postcode

Date of birth of child

Please use format day/month/year e.g. 12/05/1979

Type of Request

Copy of Parts of Medical Records

Please provide dates and details of results required

Please provide dates and details of Immunisation Summary

Please provide dates and details of Referral Letter(s)

Please provide dates and details of Clinic Letter(s)

Other (Please Specify)

Medical Records

Date Range of medical records required:

Other

Please Specify

Consent

Tick which applies

I am the Patient

I have been asked to act by the patient as detailed and who has signed the authorisation section

I am the parent/guardian of a patient who is between the age of 12 years old and 16 years old who has signed the authorisation section

I am the parent/guardian of a patient who is under 12 years old who is unable to understand the request

Signature of Applicant

Clear

AUTHORISATION OF PATIENT IF REQUEST MADE BY A THIRD PARTY

I authorise the Practice to release Personal Data requested relating to me to the above applicant to whom I have given my consent to act on my behalf.

Signature of Patient

Clear

Signature of Child

Clear

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS.

Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.