Page {{ paginatorProps.current }} of {{ }} ({{ paginatorProps.percentage }}% completed)
Details of Patient

Access to Records Application

The personal information that is provided by you on this form will be used to enable your request to be processed by the practice, this personal information will only be used in connection with the request to access your information, the information will be provided back to you electronically, unless you specify to us otherwise.

This form is for individuals requesting access to their records or on behalf of the patient (we will require evidence of consent), not for third party organisations.

Charges Payable: In accordance with data protection legislation no fee will be charged for your request, however, there may be incidences where we can charge a fee or refuse to comply with your request unless the request is deemed manifestly unfounded or excessive, please see the ICO guidance on this  Before any further action is taken,  if we do feel that we should apply a fee, we will contact you with details of our “reasonable administrative charges” in order to comply with your request.

If you would like to request Proxy Access to another patient's medical record please call our reception team on 0117 973 3790 to discuss.

Patient Details

Please enter your details below.

Type of Access


Detailed Online Access Information

Detailed online access allows you to access all of the below features through your secure online account:

  • Book appointments
  • Request repeat medications
  • View parts of your medical record:
    • Medications; you will be able to see the medications you are currently taking. If you want to request any repeat medication you will be able to do so from this screen. There is also a link to which has further information about your medication.
    • Allergies/Adverse reactions; you will be able to see what allergies you suffer from and what if any adverse reactions you have had (i.e. to medication). There is also a link to which has further information about your allergies.
    • Immunisations; you will be able to see any immunisations/vaccinations we have a record of and the date you had them. There is also a link to, which has further information about any of the vaccinations you have had.
    • Problems; this section shows you your current and past coded medical problems.
    • Consultations; you will be able to see a record of your recent consultations (coded data entry only, not text entries).
    • Test Results; you will be able to view your test results once they have been reviewed by your doctor. You will see a value, a range and a comment that has been added by your doctor.
    • Values; you will be able to view values such as your height, weight and blood pressure.

Online Access Request (Patient)

Paper Copy of Records Request (Patient)

Online Access Request (Proxy)

Paper Copy of Records Request (Proxy)

Proxy User Details

Please complete this section if the applicant requesting online access is not the patient.

Proxy users not registered at this practice: A proxy user must be registered at the same surgery as the patient in order to synchronise their personal online access account to the patient's. If the proxy applicant is not registered at the same surgery as the patient they will need to create a separate online access account for proxy access and cannot register this account using the same email address to that of any existing online access account active at another surgery.


Proxy Authorisation

To be completed by the patient if not making their own request. If patient is unable to complete this section please indicate in below declaration.

"I authorise Pembroke Road Surgery to release any personal data that I have consented to the release of in above section to the above representative whom I authorise to act on my behalf in this matter."

Proxy Access Level

Please specify the level of access for the proxy user:


I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health record(s) referred to above, under the terms of the Access to Health Records Act (1990) / General Data Protection Regulation (GDPR) / Data Protection Act 2018.

Please select one box below:

Please Note:

  • If you are making an application on the behalf of somebody else we require evidence of your authority to do so i.e. personal authority, court order etc.
  • It may be necessary to provide evidence of identity (i.e. Driving Licence).
  • If there is any doubt about the applicant’s identity or entitlement, information will not be released until further evidence is provided. You will be informed if this is the case.
  • Under the terms of GDPR, requests will be responded to within 30 days after receiving all necessary information and/or fee required to process the request.
  • Information disclosed under a Subject Access Request may have information removed; this is to ensure that the confidentiality is maintained for third parties referred to who have not consented to their information being disclosed.

If you are making a request under the Access to Health Records Act 1990, requests will be responded to within 40 days where no entries have been made to the patient/client’s record 40 days immediately preceding the date of this request, otherwise requests will be responded to within 21 days after receiving all necessary information and/or fee required to process the request.

Identification Upload

Identification Upload

In order to complete your record access application we require the below two forms of acceptable ID from the applicant:

  • Photo ID
  • Proof of address

Acceptable Identification: Photo Driving License, Passport, Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc.

We will not store these documents and we will securely delete / destroy them after our initial verification.

- failure to upload the correct documents may result in your application being rejected.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


Page you are trying to access does not exist.