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)

How do you want your medical 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 Country

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 Country

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

*