Established Patient Medical Records Request
Please make a separate request for each patient. The business office will contact
you when it is ready to pick up.
Urgent
Patient
First Name
Last Name
Birthdate
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Has the patient been seen in this office within the past 2 years?
Yes
No
Person Making Request
First Name
Last Name
Relation to Patient
Father
Mother
Relative
Other
Phone Numbers
Phone Number
Home
Cell
Work
Phone Number
Home
Cell
Work
Phone Number
Home
Cell
Work
Forwarding Physician
Name
Address
City
State
Zip
Phone Number
Fax Number
Special Instructions
Patient's New Forwarding Address
Address
City
State
Zip
Reason for Transfer
Please note the physicians are happy to copy your child's medical records and mail to the
forwarding practice at no charge for the first transfer. A return receipt is attached to the
medical records to assure they are received. If there is a second request, you will be charged
a fee.
I authorize the copy of this patient's medical records. Please be sure tp select this option
to assure completion
Comments/Suggestions
Please do not make another request if you have already filled out a form with the office.