Medical Records Request
If you would like to request a specific report or a copy of your medical chart. Please make your request here. There are applicable fees for medical records requests. Our team will contact you regarding payment.
Patient Name
*
First Name
Last Name
Patient Email Address
*
example@example.com
Patient Phone Number
*
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Physician or NP Name
*
Please Select
Dr. Victor Liao
Dr. Amy Liao
Dr. Grace Liao
Dr. Jacqueline Ho
Dr. Angela Leung
What records would you like to request?
*
Records request
Date of Report (or approximate date if not sure)
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Additional Information
Fee For Report Copies
*
I understand that there may be a fee associated with obtaining report copies from the clinic.
Fee Waiver
I would like to request to have the fee waived due to financial difficulties
Submit
Should be Empty: