Medical Record Request

Patient First Name

Patient Last Name

Date of Birth

Best number to be reached (with area code)

Is the patient a minor or under guardianship?

Yes No

Any comments or questions?

Please allow 7–10 business days for this request to be processed.
A staff member will call you when your records are ready to be released.
The patient or guardian is responsible for picking up records and signing a release.
Medical records are pick-up only.
→ They will not be faxed or emailed.

Your information will be encrypted.