Join The Adam Practice - Register online in just a few minutes. Register here.

Log in to Online Services

Home
Appointments
Prescriptions
About Us
Clinics & Services
Community Support
Health Hub

Get help from your GP by completing your health form

START HERE

Home
Clinics & Services
Subject Access Requests (SAR)
Subject Access Request Form

Subject Access Request Form

Applicant Details

First Name *

Last Name *

I am requesting *

My own medical records

The medical records of another adult

The medical records of a child

Please note if you are not the patient, and you have the permission of a third party to act on their behalf, then both persons must be present when completing this online form. We will require them to complete “The Authorisation of Patient if Request made by Third Party” declaration shown below. This section will appear when the relevant consent box is ticked at the end of the online form. If this section is not completed, we cannot process the subject access request.

Email

Date of birth

Preferred Phone number

The Medical Records of a Child

Name of child *

Address of child *

Please include postcode

Date of birth of child *

Please use format day/month/year e.g. 12/05/1979

The Medical Records of another Adult

Name of adult *

Address of adult *

Please include postcode

Date of birth of adult *

Please use format day/month/year e.g. 12/05/1979

Type of Request

View Records Copy of Parts of Medical Records Partial Medical Records Full Medical Records Other (Please Specify)

Copy of Parts of Medical Records

Results Immunisation Summary Referral Letter(s) Clinic Letter(s) Other (Please Specify)

Please provide dates and details of results required

Please provide dates and details of Immunisation Summary

Please provide dates and details of Referral Letter(s)

Please provide dates and details of Clinic Letter(s)

Other (Please Specify)

Other

Please Specify

Medical Records

Date Range of medical records required:

Consent

Tick which applies

I am the Patient

I have been asked to act by the patient as detailed and who has signed the authorisation section

I am the parent/guardian of a patient who is between the age of 12 years old and 16 years old who has signed the authorisation section

I am the parent/guardian of a patient who is under 12 years old who is unable to understand the request

Signature of Applicant

Signature of Patient

AUTHORISATION OF PATIENT IF REQUEST MADE BY A THIRD PARTY

I authorise the Practice to release Personal Data requested relating to me to the above applicant to whom I have given my consent to act on my behalf.

AUTHORISATION OF PATIENT IF REQUEST MADE BY A THIRD PARTY

I authorise the Practice to release Personal Data requested relating to me to the above applicant to whom I have given my consent to act on my behalf.

Signature of Child

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

Hamworthy Surgery

306 Blandford Road
Lytchett
Poole
Dorset BH15 4JQ

Poole Surgery

117 Longfleet Road
Poole
Dorset
BH15 2HX

Upton Surgery

Upton Cross
Poole
Dorset
BH16 5PW

Lytchett Surgery

40 High Street
Lytchett Matravers
Dorset
BH16 6BG

Lifeboat Quay Medical

Unit A Lifeboat Quay
Poole
Dorset
BH15 1AE

We provide comprehensive NHS primary care services to help you manage your health and well-being. This section contains information about our practice.

Telephone for all surgeries: 01202 676111

Please note previous individual surgery telephone numbers are still in use.

Outstanding

© The Adam Practice 2026 | Website Design by Radikls | Sitemap