Medical Documents Request Form

Request For Medical Documents

Please allow the staff to complete your request within 5-7 business days.
Main: 631-881-4569 | Fax: 631-944-8000 | Email: dovepsychiatry624@gmail.com
Patient Name:*

First NameLast Name
Date Of Birth:*

MonthDayYear
Date
Phone Number:*
Email:*
example@example.com
Today's Date:*

MonthDayYear
Date
1.) What Type Of Document / Letter Are You Requesting?*

Complete Medical RecordMedical HistoryTreatment NotesLab ResultsBilling InformationESA LetterFMLAWork / School Excusal LetterSurgery Clearance Letter504 Plan LetterOther
2.) If you chose "ESA Letter" please fill in the blanks:
Name Of Pet:   Name*   . Type Of Pet:   *   .
Weight Of Pet:   Weight*   . Age Of Pet:   Age*   .
Breed Of Pet:   Breed*   .
Please provide a brief description (be as specific as possible) to what your paperwork is for, and what you want added to it.
Disclaimer: Please allow the staff from Dove Psychiatry, to complete your request within 5-7 business days. Also, please be aware that there is an additional fee for letters and paperwork. Call or text the office to inquire about pricing, and payment must be sent before paperwork is sent.
Should be Empty:

Request For Medical Documents