Request for Medical Records

Please fill out the form below if you are requesting medical records:

Patient Name

Date of Birth

Patient Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email

Phone

Birth Medical MEDICAL

MEDICAL RECORDS INFORMATION

Please release my medical records to:

Physician/Clinic's Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Medical Records Release Terms & Conditions

I accept the terms & conditions

1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Patient's Signature

Clear Signature

Date