Medical Records Request

Medical Records Request

by Patient or Guardian
Patient's Name*

First NameLast Name
DOB*

MonthDayYear
Date
Contact Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*

First NameLast Name
Relationship to Patient*
(i.e. mother)
Email*
example@example.com
Message
Payment

Please call our office at (512) 478-8116 to process payment and complete your request.
Medical Records Requested*

Office Visits ($10)X-Rays ($10)Office Visits + X-Rays ($20)
Beginning Treatment Date*

MonthDayYear
Ending Treatment Date*

MonthDayYear
I request the records be provided to me via:*

Email (*X-Rays cannot be emailed)Paper copyOn a CD
I would like the records delivered to me by:*

USPS mail ($1.75)I will pick upI will have someone pickup my recordsOther
Person picking up my records (if applicable)
Please specify who
By signing this form, I understand the information in the record may include personal, sensitive information. I also understand and accept full responsibility for the medical records I am about to receive and I relinquish CTPO of any and all accountabilities concerning these medical records. I acknowledge the potential risks associated with sending medical records via email, including the possibility of unauthorized access, and consent to receive medical records electronically (if requested) from CTPO at the email address provided.
Signature*

Clear
Today's Date*

MonthDayYear
*If you are picking up records, please make sure to bring a valid ID.

Please call our office at (512) 478-8116 to complete payment and process your request.
Should be Empty:

Medical Records Request

Payment