Patient Online Access to Medical Records

This form is to request or remove access to your online medical records. You can also use this form to request amendments to entries within your medical record

Please complete the appropriate section(s) below:

1.      Patient Details (Mandatory)

2.      Application to Access Online Medical records

3.      Remove Access to Online Medical records

4.      Application to Amend Medical Record Entry Details

*Before completing this from, please think carefully before answering the question below*

This section is to request access to your online medical record

This section is to remove/restrict access to your online medical record.

This section is to request a change to an entry within your medical record