The information you supply in this form will only be used for the purpose of identifying the personal data you are requesting and responding to your request. You are not obliged to complete this form to make a request but doing so will make it easier for us to process your request quickly. You agree that a copy of your verification will be safely stored by The PC Clinic Business Limited for our internal records and for the sole purpose of confirming your identity for the duration of 6 months. After the retention period all personal information will be deleted.

Section 1: Details about the person requesting information

Section 2: Are you the data subject?

To ensure we are releasing data to the right person we require you to provide us with proof of your identity and of your address. Please supply us with a photocopy or scanned image (do not send the originals) of both of the following:

  1. Proof of identity (Passport, Driving License, Birth Certificate, National Identity Card)
  2. Proof of Address (Utility bill, credit card statement (no more than 3 months old), HMRC Tax document (no more than 1 year old)

If we are not satisfied you are who you claim to be, we reserve the right to refuse to grant your request
Details of the Data Subject
Section 3: Details of the data subject (if different from section 1)

Section 4: What information are you seeking?

Please note that if the information you request reveals details directly or indirectly about another person we will have to seek the consent of that person before we can let you see that information. In certain circumstances, where disclosure would adversely affect the rights and freedoms of others, we may not be able to disclose the information to you, in which case you will be informed promptly and given full reasons for that decision.
While in most cases we will be happy to provide you with the copies of the information you request, we nevertheless reserve the right, in accordance with section 8(2) of the DPA, not to provide you with copied of information requested if to do so would take "disproportionate effort", or in accordance with Article 12 of the GDPR to charge a fee or refuse a request if it is considered to be "manifestly unfounded or excessive". However we will make every effort to provide you with a satisfactory form of access or summary of information if suitable.

DECLERATION: I confirm that I have read and understook the terms of this subject access form and certify that the information given in this application to The PC Clinic Business Limited is true and I understand that it is necessary for The PC Clinic Business Limited to confirm my/the data subject's identity and it may be necessary to obtain more detailed information in order to locate the correct personal data.