RAINBOW PEDIATRICS MEDICAL RECORDS TRANSFER FORM

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We are so sorry to see you go. If there is anything we can do to change your mind, please contact us immediately. Please provide us with the following information:

We are happy to send your medical records via fax to your new Pediatrician’s office free of charge. Please provide us with their information below:

If you are requesting that your child’s medical records be sent to you directly, there is a fee of $30 per patient and we ask that you pay in advance with a credit card. The records will be copied onto a USB drive for your convencience. Your child’s records can be picked up in our office within 30 days of your initial request or will be mailed to the following:

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