Medical History Report (Subject Access Request)

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

Please state exactly what information you are requesting. If ENTIRE medical records are required please state. We will process your request within 28 days of receipt of your request.

Please note: You will need to bring photo ID when collecting your report.

Medical History Report Request (Subject Access Request) - Thatcham

Medical History Report Request (Subject Access Request) - Thatcham

If you are human, leave this field blank.

First Name: *

Surname: *

Phone Number:

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Email Address: *

Named GP (if known):

Please specify your request: *

Entire medical record

Information required between specific dates

Start Date

Please use the format DD/MM/YYYY

End Date

Please use the format DD/MM/YYYY

Relating to what medical condition(s)? *

Do you require copies of correspondence/hospital letters we hold? *

Yes

No

Any further comments?

*

I am able to collect my paperwork from Thatcham Medical Practice

*

I confirm that my request is not urgent and that I may be contacted by the practice for further information or clarification about the request. By submitting this form, you indicate that you are the individual named above or have legal responsibility. The practice cannot accept requests regarding your personal data from anyone else, including family members. If medical information has already been given in the past 2 years the practice does not need to reissue it. Repeat requests will be/may be chargeable.