Request Medical Records

You may request up to 3 studies on this form. Please enter the phone number you can be best reached at. Our staff will use this number to contact you and verify information before the records are released.

Medical Records Request Form

First Name*
Last Name*
Date of Birth*
Phone*
Email*
Type of Study
Exam Date
Type of Study 2
Exam Date 2
Location*
Please choose a pick up location or delivery by mail.
address
Date Needed
Please allow 48 hours.
Physician images will be taken to*
Designee (Name of person picking up the records)*
Images will be provided on CD, unless film is requested. If your images will be picked up by someone other than yourself, please indicate their name. Photo ID is required to release your records to you or your designee.
Additional Comments

Request Medical Records

Medical Records Request Form

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