Records request

All fields are required unless marked optional.

Who is making this request?

I am the patient
Send a copy of my records to me. I'm requesting for someone else
Parent or guardian, power of attorney, or personal representative. I'm a doctor's office or other organization
Requesting records with the patient's signed authorization.

Your information

First name

Last name

Date of birth

Mobile phone

Is this the same email or phone number you used with our office?

Yes, at least one of them is the same. No, both have changed, or I'm not sure.

What you'll receive

The complete record: all visit notes, lab results, imaging reports, and documents. It arrives as a ZIP folder with one PDF per document, so it's easy to forward a single lab or visit note to a new doctor.

Signature I confirm that I am the person named above, or that I am legally authorized to request these records on their behalf. I understand that submitting a false request may be unlawful.

Type your full name as your signature