Request Patient Records

Full Name*
Date of Birth*
Patient Phone Number*
Patient Email Address*
Exam Requested
Date of Testing*
Information Request*
- Reports
- Images
Release Records to*
- Doctors Office
- Myself
If Doctors Office - Office Address
Mode of delivery*
- will pick-up (prepare to show ID )
- Delivery by Courier
- Delivery by Mail
Delivery Address
Additional Information
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Phone
This field is for validation purposes and should be left unchanged.