PATIENT RECORDS RELEASE FORM

Please fill out this form and attach the requested files, sign, and submit. You can also DOWNLOAD the form here and email it back in at your convenience.

  • Pease attach a copy of the records as indicated below:

    • Full health record maintained by this provider
    • X-Rays
  • Drop files here or
    Accepted file types: jpg, jpeg, gif, png, pdf.
  • By submitting this form, you agree to allow the transfer of your personal medical information via electronic mail. Forms on this website are encrypted and protected by SSL security.
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