Consent to Request Previous Medical Records

As part of your planned surgery at Kinvara Private Hospital, we need to obtain your complete medical history from your previous healthcare providers. This is essential to ensure safe and effective care.

What records are we requesting?

GP Records: Complete medical history
Hospital Records: Previous treatments, surgeries, consultations
Specialist Records: Specialist consultations or treatments
Diagnostic Results: X-rays, scans, blood tests, imaging
Operative Notes: Surgical reports from previous procedures
Pathology Reports: Tissue analysis or laboratory results

How will your information be used?

Used solely for clinical assessment and surgical planning
Stored securely in accordance with NHS and private healthcare standards
Accessed only by healthcare professionals directly involved in your care
Not shared with third parties without your consent (except where required by law)

Under the GDPR and Data Protection Act 2018, you have the right to know how your data will be used, withdraw consent at any time, and request copies of your records.

Name *

First

Last

Address *

Address Line 1

City

State / Province / Region

Postal Code

Date of Birth *

Phone Number *

Email Address *

GP Name (if known)

GP Address (if known)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name (and address if known) of the hospitals or clinics where you had your treatment

Consent *

I give my explicit consent and authorise Kinvara Private Hospital to request and obtain copies of my complete medical records from all healthcare providers listed above.I understand that my medical information will be handled in accordance with UK data protection laws, used solely for my medical care and treatment planning, and that I can withdraw this consent at any time.I understand this consent serves as my written authorisation for the release of my medical information to Kinvara Private Hospital for the purposes outlined above.

Signature *

Today's Date *

8 July 2026