Access To Medical Records Request Form

Application for Access to Medical Records

Details of the Records to be Accessed:

Are you requesting access to your own medical record? *

Details of the Person who wishes to access the records, if different to above:


I agree to my GP practice giving me access to my record online
I agree to use the system in a responsible manner in accordance with all instructions given to me by the practice. If not access may be withdrawn
If I see information which does not relate to me, I will immediately log out and report the matter to the practice as soon as possible
I agree that it is my responsibility to keep my username and password secure. If I think these have been shared inappropriately I will reset them using the instructions supplied. I am also responsible for keeping safe any information I may print from the record
I agree that my details below may be used to contact me about how useful I find the service and whether it could be improved
I understand that online access is granted at the discretion of the practice, taking into account my best interests. I will be informed of any decision to withdraw the service. Please note, this does not affect your rights of Subject Access under GDPR

Other Considerations

The practice makes every effort to record information as accurately as possible, however there may be information that you do not feel is correct.
If I notice any inaccuracies with my record, I will inform the practice manager as soon as possible of any errors or omissions
I understand that I may see information on my record that I was unaware of/have forgotten about that could cause distress
I understand that as before, I will be informed directly, by the practice, of any test results which require further action. However I understand that I may see these results online before the practice has been able to contact me. This could be while the surgery is closed and there is no one available to discuss them with me
By signing this form you will be giving us your permission to go ahead with setting up the service for you. If you decide not to join, or wish to withdraw, it will not affect your treatment in any way.