View Your Medical Record Online

If you would like to view your medical record online we will require you to fill out the following form.

This can be done by filling out the form below or by downloading a copy here and handing it in at Reception (PDF, 131KB).

Details of the record to be accessed

Patient Surname

Forename(s)

Date of Birth

Address

Details of the person who wished to access the record (if different from above)

Surname

Forename(s)

Date of Birth

Address

Telephone Number

Relationship to Patient

Declaration: I declare that the infomation given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the data protection act 1998

What level of access are you applying for

Core Summary Care Record (Gives access to allergies and medication)

Detailed coded record (Includes access to allergies and medication)

Please select whichever statement applies

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Parkside Medical Practice • Park View Centre, Chester Road North, Brownhills, WS8 7JB.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Local Services