Request a copy of your medical records If you've attended one of our hospitals or our diagnostic clinic, you can request a copy of your medical records. Just complete the form below, and one of our team will contact you to discuss your request. Location - Select -Blackrock ClinicGalway Clinic Hermitage ClinicLimerick Clinic First name Last name Date of birth Email Phone number (in intl format e.g. +353 85 012 3456) Address City County Eircode Other name (if any) Maiden name Please enter the timeframe of the medical records you’re asking for (e.g. January 2015–December 2020) In order for us to verify your identity, we’ll follow up with an email asking you to provide a copy of one of the following. Please tick the document you intend to provide: Passport Drivers licence Other photo ID Proof of address Records can be sent to your address or via secure, encrypted email to the email address provided in this form. Please specify how you wish to receive your records: Via email Via post CAPTCHA