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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.

Once the form has been submitted you will instantly receive a confirmation message to say we have received it.

If you don't receive a message upon 'Submit', please check that all the required fields are filled in and then try again.

SECTION 1: Patient details


Full Name*

Date of Birth*

NHS Number*

LHCH Hospital Number (if known)

SECTION 2: Request details

Organisation Name*

Requesting department*

Staff Name*

Job Title*


Email ( or only)*

CC Email ( or only)

Reason for requesting access

Tick as applicable:

Specify Date and/or Specific Details:

Date to attend

Please specify specific details:

SECTION 3: Records or information required

Health Records:

Tick as applicable*

Details of Health Records needed:

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