Subject Access Request Form This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-Practice365-in-2020/). Important: Delete this tip before you publish the form.About YouYour Name First Last I am requesting: My own medical records The medical records of another adult The medical records of a child Your Email Address Email Address Confirm Email Address Your PhoneDate of Birth MM slash DD slash YYYY Type of Request View records Copy of parts of medical records Partial medical records Full medical records Consent I am the Patient I have been asked to act by the patient as detailed and who has signed the authorisation section I am the parent/guardian of a patient who is between the age of 12 years old and 16 years old who has signed the authorisation section I am the parent/guardian of a patient who is under 12 years old who is unable to understand the request Tick which appliesSignatureThis form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.Your Consent I consent to the practice collecting and storing my data from this form.