Medical Record Release Form

Patient Information
Record requests will be responded to within 2 business days. You will not be charged if no records are located. Costs for records between 1-5 pages is $15. Charge will only be submitted if records found and then records will be sent via email.
Patient Name

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Person/Organization to Release Information
I, the patient, authorize and request the disclosure of all protected information I select below full and complete.

All immunization, TB skin test, lab work .
Date

MonthDayYear
Date
My Products
prevnext( X )
All Immunization, TB and lab records requestedRecords
$15.00 Quantity

Total

$0.00
Signature

Clear

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.