Access to Medical Record Request

Please use this form to request a copy of your medical records.

Your Details

Name *

Date of Birth *

NHS Number

Medical Record Request

Practice name *

Ballards Walk Surgery

The Gore Surgery

Please detail what information you are requesting. *

Please explain the reason you are requesting to receive a copy of your Medical Records. *

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Page last reviewed: 23 October 2025
Page created: 30 July 2021

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