Records Access and Understanding Safety Checklist Questionnaire This form is used to sign people up for Full Records Access and Understanding Name First Last Date of birthMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Street Address Address Line 2 City Postcode Email Telephone numberMobile numberI wish to have access Accessing my detailed coded medical record I wish to access my medical record online and understand and agree with each statement (tick) 1. I will be responsible for the security of the information that I see or download 2. If I choose to share my information with anyone else, this is at my own risk 3. If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible 4. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible 5. If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible. Upload File Drop files here or Select files Max. file size: 1 GB. upload a picture of your official ID (driving license/passport etc)SignatureDate DD slash MM slash YYYY Comments OptionalThis field is for validation purposes and should be left unchanged.