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... Request a Data Subject Access Request?

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01952 460414

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Data Subject Access Request

Required fields are marked with an asterisk (*).

*Please note - This is not a mandatory form but will assist us in dealing with your data subject access requests more efficiently.

Please provide your details below

First Name*

Surname*

Any Previous Surnames

House Name/No:

Street

Email address*

Patient Date of Birth*

Town

Postcode

Telephone Number*

*I would like to request a copy of my medical records, please tick the most appropriate option.

A copy of my electronic medical records during a specific date range (Please select date range below)

A copy of my electronic medical records for a specific condition

A paper copy of my medical records

(Records will be emailed to you via the email address you have provided above)

From: 00/00/0000

To: 00/00/0000

Please give a detailed reason for this specific request, including any conditions or date ranges:

Shifnal & Priorslee Medical Practice will require you to upload two forms of ID to allow us to proceed with your request.

1 x Photo ID
1 x Proof of Address

Please upload your photo ID here*

Please upload your proof of address here*

Disclaimer, please read carefully

I understand there is no fee for a data subject access request, only in exceptional circumstances.

I am aware that the records provided to me will be only from my electronic medical records, unless I state otherwise.

I am aware that this information will be provided to me within one month from Teldoc receiving this request. If there is a delay, Teldoc can extend this to two months, but I will be informed, with an explanation, why this extension is necessary.

I understand I will need to provide one form of photo ID and one form of proof of address if I am collecting paper copies of my records. This is to ensure Shifnal & Priorslee Medical Practice conforms to the Data Protection Act.

*Please tick to acknowledge you understand the above disclaimer, explaining this process, type of records provided to you and the ID requirements.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. 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.

Are you human?*

This field should be left blank

Please note this form is not to be used for the following purposes:

Medical matters, Prescription requests, Patient Access requests, Appointment requests or Complaints. Medical matters cannot be dealt with via this form. If you have a query regarding a medical matter please telephone reception to make an appointment to see the appropriate person.

Other forms available

Register as Patient

Please visit our Patient Registration page and fill in the health questionnaire to register as a patient at Teldoc.

Change of Address

Please visit our Change of Name Form to update your details

Provide Feedback

Please visit our Feedback Form to provide feedback, make a suggestion or complaint.

More forms

Please visit the How Do I Portal for more forms

Find out more...

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Visit the How Do I portal for information on how to make an appointment, register at the practice and change your details

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01952 460 414

Haughton Road, Shifnal, Shropshire, TF11 8DD

Gatcombe Way, Priorslee, Telford, TF2 9GZ

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