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Medical Records Access Request Form
(Child Aged Under 11 Years)

Parents with parental responsibility and other authorised individuals may make a Data Subject Access Request (DSAR) to receive information included in their medical records for children under 11 years. This form enables requests for a DSAR to be made, explains who may do this, and the process they need to follow.

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Who Can Make a DSAR for a Child under 11 years?

  • Parents with parental responsibility

  • Guardians and court appointed individuals

  • Authorised third parties: Individuals with written permission from a parent with parental responsibility or a legal guardian (for example solicitors).

Thanks for submitting!

*This form is for Modality Partnership Patients Only and must be completed and signed in order for us to process your request*

Section 1: Your Details

What is the main purpose of your request? (Tick all that apply) Required

Section 2: Details of the Child

Section 5: What Records are you Requesting?

Please be as specific as possible. This helps us provide the information quickly and reduces delays.

Sources of information to include: (Tick only one) Required
Proof of ID
Upload supported file (Max 15MB)
Supporting Documentation
Upload supported file (Max 15MB)

​Understanding the purpose of your request helps us ensure you receive the correct information in the most helpful format.

Section 6: How Would you Like to Receive the Information?

Please tick one option: Required

Section 7: Proof of Identity/ Legal Eligibility

To keep your information safe, we need to confirm your identity. Your practice team may be able to vouch for you to confirm your identity. If they are unable to do this, we will require you to provide proof of identity. Please tick one option below to show which type of proof you will provide.

Please tick only one option: Required

Section 8: Declaration

I declare that the information 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 General Data Protection Regulations.

I am requesting: (Tick all that apply)

Section 3: The Relationship with the Child 

Tick only one Required

Section 4: Purpose of your Request 

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