Medical Record Request

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Applicant's Details
Patient's Details
Please included any former names
Please double check you've entered the correct email address

Help Us To Help You 

Providing a NHS Number means that we can find a patient record more accurately, saving time and resources. 

How to find your NHS Number 

If known
 
  
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Additional Information

To help us save time and resources please let us know if you want just part of your medical record, such as information relating to a specific illness or time period. 

 
Proof of Authority

If you are making an application on the behalf of somebody else we require evidence of your authority

Please upload a copy of your evidence

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Details of where medical records are to be sent
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Declaration

You are requesting access to the records for

  • Name: 
  • NHS Number: 

Please return to the previous pages to make any amendments

  • We aim to respond to you within 28 days, however, if we need additional information in order to complete the request, it may take longer.
  • We have an obligation under the GDPR and DPA 2018 to ensure that any information is provided only to the patient, or their authorised third party, so where you request information to be sent to an address or email address we do not hold on file for you, we may ask for proof of identity.
  • If you think that information in your health record is incorrect, or you need to update your personal details (name, address, phone number), please contact us. In some circumstances we are unable to amend the information on your record and if that is the case we will explain the reasons to you
 
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Privacy Consent

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Providing NHS Services

Contact

Montgomery-House Surgery
Piggy Lane
Bicester
OX26 6HT

Telephone: 01869 249222

The Practice

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