have received from New Orleans Podiatry Associates and its affiliated agents a copy of my medical records in its entirety, including but not limited to physician progress notes, operative reports, radiology reports, laboratory results, and any external or internal information that has been created or collected on my behalf.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
New Orleans Podiatry Associates
2626 Jena Street, New Orleans, LA 70115 - t. 504.897.3627 f. 504.897.3339 3939 Houma Blvd, Bldg. 5, Ste. 217, Metairie, LA 70006 - t. 504.457.2300 f. 504.897.3339nolapodiatry.com | email@example.com
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.