Application for Access to Online Medical Record

To request access to your online medical records, please fill out this form.

To complete your request, you will need to upload proof of identity, this should include photographic ID and proof of address.

If you are human, leave this field blank.

Section

Address:

Level of access requested:

Select one of the following: *

Coded Access - This details current and previous medical conditions, immunisations, allergies and general health status such as height, weight, blood pressure

Full Access - This includes Coded Access as above and Free Text information that clinicians have manually typed onto your record such as details discussed within an appointment or consultation

I will be responsible for the security of the information I see or download

If I choose to share my information with anyone, it is at my own risk

I agree to contact the practice as soon as possible if any of the following applies: *

If I suspect that my account has been accessed by someone without my consent

If I see information on my record that is not about me or is inaccurate

If I think that I may come under pressure to give access to someone else unwillingly

I understand that no appointment will be available for me to discuss my online medical record which is a representation of my full health record

To complete your request, please upload proof of identity, this should include photographic ID and proof of address

Maximum upload size: 67.11MB

I confirm that I have uploaded proof of identity which includes photographic ID and proof of address (If you are unable to upload ID, please contact the practice)

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Application for Access to Online Medical Record

Application for Access to Online Medical Record

Section

New Patients