Patient Medical Record Request

Patient Medical Records Request
Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
All medical record request take up to 30 days to process

Fee for Records: $6.50

Fee for MRI/Xray Disc: $5.00 per study
What records are you needing?

Clinic RecordsMRI DiscSurgery Records
We are unable to email records as it is not a secure method
How would you like your records delivered:

Mailed to address on Signed Release.Pick up in office.
If your address has changed since you were last seen please visit our website and complete a new Signed Release.
Should be Empty:

Patient Medical Records Request