Strictly confidential once completed
This form may be used if you wish to:
- send us your request using email or
- type in the information and then print off to post to us.
Please enter as much information as you can because this will help us to deal with your request as quickly as possible. The boxes will expand as you type into them.
If you have any queries or need help with completing your application please do not hesitate to contact us either by telephone or by email:
Direct dial: 01332 623760 Switchboard: 01332 623700 ext 33760
Once completed you can either email your form attaching any relevant documents or post to us:
Access to a Health Record
IM&T and Records
Kingsway House East
Derby, DE22 3LZ