Release of Medical Records to Neighborhood Pediatrics

Please use this form to request medical records

Child's Name (First and Last)

Date of Birth

Name of Person Requesting Medical Records Release (First and Last)

Relationship to child

Name, Address, Fax number to Release Information:

Type of Records to be released:

Vaccine Record

Growth Chart

Entire Medical Record

Reason for Medical Release

Needing Immunization Record

Records for a specialist

Changing Providers (leaving the office for a new office)

Personal Copy

Other

Driver's License or ID or Authorized Adult

Add file

Please upload a file

I understand that a medical record release charge may be billed in accordance to the Texas Medical Board's fee schedule.

Today's Date

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