Medical Record Requests
Please fill out the form below to request a copy of your medical records.
Name
*
First Name
Last Name
Email
*
example@example.com
Patient's Name (if different than the requester)
First Name
Last Name
Relationship to Patient
(Ex. Parent or Guardian)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Location Visited
*
Archer Heights, Chicago, IL
Aurora, IL
Blue Island, IL
Bolingbrook, IL
Bourbonnais, IL
Burbank, IL
Calumet Park, IL
Carol Stream, IL
Cedar Lake, IN
Chicago Ridge, IL
Cicero, IL
Crown Point on 109th & Broadway, IN
Crown Point on Burr & 30, IN
Dyer, IN
Elmhurst on Butterfield, IL
Elmhurst on York Street, IL
Gage Park, Chicago, IL
Garfield Ridge, Chicago, IL
Griffith, IN
Griffith next to Walgreens, IN
Hammond on 5th Avenue, IN
Hammond on Sibley, IN
Hobart, IN
Lakeview, Chicago, IL
Logan Square, Chicago, IL
Lombard, IL
Matteson, IL
Mayfair, Chicago, IL
Melrose Park, IL
Merrillville, IN
Merrillville next to Walgreens, IN
Michigan City, IN
Mt. Greenwood, Chicago, IL
Munster, IN
Norridge, IL
Northbrook, IL
Portage, IN
Portage next to Walgreens, IN
Portage Park, Chicago, IL
Richton Park, IL
River Forest, IL
River North, Chicago, IL
Roscoe Village, Chicago, IL
Schererville, IN
Skokie, IL
Tinley Park on Harlem, IL
Tinley Park on LaGrange, IL
West Loop, Chicago, IL
Westmont, IL
Wheaton, IL
Wicker Park, Chicago, IL
Willowbrook, IL
Date of Requested Visit
*
-
Month
-
Day
Year
Date
Specific Information Requested
*
Questions or Comments?
Submit
Should be Empty: