Medical Records Request

Medical Records Request
Patient's Name *

First Name Middle Name Last Name
Patient's Date of Birth *

Month Day Year
Patient's Gender *

Male Female
Patient's Phone *
Patient's Email *

Confirmation Email
What type of medicals records to are you requesting? *

Consultation/progress notes Procedure reports Pathology/biopsy results Lab results Imaging results (no CDs)

Where to send records?

Emailed to email address on file $ 5.00

Printed for pick up $ 8.00

Mailed to address on file $ 12.00

Faxed to another doctor's office Free

Faxed to a hospital or healthcare facility Free

Provider's Information To Fax Records
Provider's Name *

First Name Middle Name Last Name Title
Provider's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Provider's Phone *
Provider's Fax *
Hospital's or Healthcare Facility's Information
Facility's Name *
Facility Address *

Street Address

Street Address Line 2

City State

Zip Code
Facility's Ward, Unit, Floor, or Room Number.
Facility's Phone *
Facility's Fax *
*
Signature *

Must be signed of patient, healthcare proxy, or medical power of attorney. Clear
Should be Empty: