Medical Record Request

MEDICAL RECORDS REQUEST
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
I hereby request the following information:*

Medical RecordsBilling SummaryX-Ray CD ($15)Other
Which office are you primarily seen at?

CummingBufordDuluth
I hereby authorize Academy Orthopedics, LLC to release medical records as indicated above and understand that records may include information regarding HIV, psychiatric and mental illness, drug/alcohol abuse records, venereal disease and any other statutory protected diseases.
Patient or Legal Guardian Signature*
Date

MonthDayYear
Date

MEDICAL RECORDS REQUEST