Continuance of healthcare request for access to health records

(*) Mandatory - All the required fields must be filled out in order for this form to be submitted.

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SECTION 1: Patient details

Title*

Full Name*

Date of Birth*

NHS Number*

LHCH Hospital Number (if known)

SECTION 2: Request details

Organisation Name*

Requesting department*

Staff Name*

Job Title*

Phone*

Email (nhs.uk or nhs.net only)*

CC Email (nhs.uk or nhs.net only)

Reason for requesting access

Tick as applicable: Current inpatientDue to attend outpatient appointment (Please insert date opposite)Due to attend pre-op assess (Please insert date opposite)Due to have surgery (Please insert date opposite)TCI (Please insert date opposite)Awaiting date for surgeryRadiology compatibilityFor Dr infoFor GP infoGeneticsOther (Please insert specific details opposite)

Specify Date and/or Specific Details:

Date to attend

Please specify specific details:

SECTION 3: Records or information required

Health Records:

Tick as applicable* Discharge summaryDevice detailsOperation noteClinic lettersResult reportsOther

Details of Health Records needed:

Specify type and date range or date of procedure/attendance*

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