Podiatry Self-referral form

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This field is for validation purposes and should be left unchanged.

Please describe the information you are seeking(Required)

Please state whether you are seeking a full record or just a part of a record covering a specific incident or date range (for example may 2018 to August 2019)(Required)

First Name(Required)

Last Name(Required)

Date of Birth(Required)

CHI Number (if known)

Full postal address (including postcode)(Required)

Full name (If making a request on behalf of another person)

Relationship to the person whose information you are requesting (if making request on behalf of another person)

Company Name (Solicitors only)

Postal address of person making request (if different from above)

Email address (of person making request)(Required)

Mobile telephone number (of person making request)

Identification(Required)

Drop files here or

Max. file size: 128 MB.

Please upload 1 attachment with proof of identification (x2 such as a driving license or passport and proof of address such as utility bill or council tax bill) and proof of entitlement to make this request on behalf of another person if applicable.

Consent

If you are completing this application on behalf of another person, the Practice will require their authorisation before we can release the data to you. The person whose information is being requested should sign the relevant section within the online form. If the patient is a child (i.e. under 16 years of age) the application may be made by someone with parental responsibilities – in most cases this means a parent or guardian. If the child is capable of understanding the nature of the application, his/her consent should be obtained or, alternatively, the child may submit an application on their own behalf. Children will, generally, be presumed to understand the nature of the application if aged between 12 and 16. All cases will be considered individually. You will appreciate that health data relating to any individual is highly confidential and the Practice must ensure that it releases such data only to the person to whom it relates, or to a person authorised to act on his/her behalf. Please complete this online Request Form as fully and accurately as possible to enable us to locate the exact data you require. The General Data Protection Regulations The Data Protection Act 2018 is the UK’s implementation of the General Data Protection Regulation (GDPR). Gives you the statutory right of access to any information, manual (paper) or computerised. You may wish to authorise someone else to make your application on your behalf. If you have parental responsibilities, you may make an application to see your child’s notes, if they are under the age of twelve years. You do not have to give a reason for applying for access to your General Practice records. If you do not need access to your entire records, it would be helpful if you would inform us of the periods and parts of your health records that you require, along with details which you may feel have relevance (e.g. Clinic type, location, dates)

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Podiatry Self-referral form

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