Birth Record Release

BIRTH RECORDS

Patient’s Last Name:

Patient’s First Name:

Please release ALL birth records including maternal blood type, maternal serologies, newborn labs, complete discharge summary, hearing screen results and newborn screening record, including laboratory test results for my child:

Last Name:

First Name:

Date of Birth:

to DuPage Pediatrics, Ltd.

The fax number is 630-810-0937.
Thank You,

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Parent’s Signature

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