Subject Access Request Form

Subject Access Request Form
Details of the person requesting information
Are you the patient?*

YesNo
Please tick the appropriate box and read the instructions which follow it.*

I enclose proof of my identity see below
Please confirm the appropriate box and read the instructions which follow it.*

I confirm I am acting on behalf of the patient. I have enclosed their written authority and proof of their identity and my own identity see below
Name of patient*

First NameLast Name
Patient's telephone number*
Patient's Email address*
example@example.com
Patient's address (Start by typing your postcode into the first field)*
To ensure we are releasing records for the right patient, please provide both of the following:

1) Proof of Identity: Passport, photo driving licence, national identity card, birth certificate.

2) Proof of Address: Utility bill, bank statement, credit card statement (no more than 3 months old); current driving licence; current TV licence; local authority tax bill, HMRC tax document (no more than 1 year old).

If we are not satisfied you are who you claim to be, we reserve the right to refuse to grant your request.
Patient's proof of Identity*

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Cancelof
Patient's proof of Address*

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Cancelof

As you are completing this form on behalf of the patient, we also require your information and consent from the patient to proceed.
Full name of person requesting on behalf of the patient*

First NameLast Name
Contact telephone number of person requesting on behalf of the patient*
Email address of person requesting on behalf of the patient*
example@example.com
Address (Start by typing your postcode into the first field)*
Patient's written authority*

Browse Files

Cancelof

What information are you seeking?*

Copy of radiographs (X-rays)Copy of appointment historyCopies of radiographs & appointment historyOther
How would you ideally like the information?*

EmailCollect in person (allow 7 days from when you have dropped off a USB)Posted (As above and will incur postage fees paid prior to sending)
Please note that any attempt to mislead may result in prosecution. I confirm that I have read and understood the terms of this subject access form and certify that the information given in this application to Gentle Dental Care is true. I understand that it is necessary to confirm my / the data subject's identity and it may be necessary to obtain more detailed information in order to locate the correct personal data. I confirm that if I select email, postal errors, loss of data, corruption etc I am responsible for any errors, omissions in my email address and the company can not be held liable for xyz.
Signature*
Date*

DayMonthYear
Date
Please note we will process your request within 30 days of submission.
Should be Empty: