Subject Access Request Form (DSAR)

 Under the new EU General Data Protection Regulation (GDPR), you have the right to request for all or part of your personal information we hold and how we process it.

 In order for us to best fulfil your request, you are required to complete this form legibly, preferably by computer and returned via email. As soon as we receive your completely filled request form, we will respond to you within 30 days, either with the data, or with further queries if required to access the data you have requested.

 The information you supply in this form will only be used for the purposes of identifying the personal data you are requesting and to enable us respond to your request accordingly.

Section one: Details of the person requesting the information

Full Name 

Address

 

Phone number 

Email 

Are you the data subject?

Yes I am requesting access to my own data

No I am acting on behalf of the data subject (applicable under power of attorney or for children under 16 only) and I have attached proof of my right to access the data

Section two: Details of the data subject (if answered ‘no’ above or your details have changed since our record was made, for example by marriage)

Full Name 

Address 

 

Phone number

Email 

Date 0f Birth 

Please use the box below to describe in detail the information you are requesting, to help us process your request with upmost speed and accuracy.

 

 

 

Section three: Identification and proof of address

To enable us to verify your identity, you are required to provide us with proof of identity and your address. This is to ensure we are releasing your data to the right person. Please provide us with a photocopy or scanned image of at least 1 each of the two categories below:

1) Proof of identity (e.g. passport, photo driving licence, or birth certificate)

2) Proof of address (e.g. utility bill, bank statement (not later than 3 months), current driving licence or most recent council tax bill)

Be informed that if we are not satisfied you are whom you claim to be, we reserve the right to refuse your request and you will be notified with clear explanation for the refusal. You have the right to appeal this decision in line with the regulation.  

Section four: intended destination for your personal information

If you would like your information to be sent to a different location, such as another dental practice, please fill in this section with the relevant details.

Name 

Address 

 

Email 

Section five: Declaration

I confirm that I have read and understood the terms of this Subject Access Request form and certify that the information given to Buxton Dental Practice in this application is true. I understand that it is necessary for the practice to confirm my identity (the data subject’s identity if applying as a representative) and it may be necessary to obtain more detailed information in order to locate the correct personal data I am requesting.

Type name to complete declaration 

Dated 

Please return completed request form, identification and proof of address to the Data Protection Officer Charlotte Smith:

Email: charlotte.townsend@nhs.net

Post: Charlotte Smith, Buxton Dental Practice, 3 Belmont Terrace, Terrace Road, Buxton, Derbyshire, SK17 6DZ

Correcting Information: On receipt of the requested information, if you believe your information we hold is outdated, incorrect or processed in ways other than consented, please contact the Reception team either by email: info@buxtondental.co.uk or by writing to the address above with suggested amendments.