Access to Medical Records - Ballards Walk Surgery

Access to Medical Record Request

Please use this form to give consent for access to your medical record.

Your Details

Name *

Date of Birth *

NHS Number

Medical Record Request

Practice name *

Ballards Walk Surgery

The Gore Surgery

Please provide the reason for which you are requesting to receive a copy of your Medical Records. *

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Page last reviewed: 30 July 2021
Page created: 30 July 2021