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 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* Send