Electronic Health Request Form
Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Email
*
example@example.com
Phone
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requested Item(s)
Records request
REFILL REQUEST DETAILS - Please include name of medication, dose, frequency (how often you take it), and pharmacy information below. Incomplete or inaccurate information may cause delay or denial of request.
RECORDS REQUEST DETAILS - Please include clinician or facility name to which to release the records.
AUTHORIZED SIGNATURE (Patient signature if 18 yrs or older. Guardian signature if patient is younger than 18 years.)
*
Printed Name of Signatory
First Name
Last Name
Relationship of Signatory to Patient
Please Select
Self
Parent / Guardian
Spouse
Power of Attorney
Other (additional information required)
Continue
Continue
Should be Empty: