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
*
Blue Island, IL
Bourbonnais, IL
Calumet Park, IL
Cedar Lake, IN
Crown Point, IN
Dyer, IN
Gage Park, Chicago, IL
Hammond, IN
Lakeview, Chicago, IL
Merrillville, IN
Munster, IN
Mt. Greenwood, Chicago, IL
Portage, IN
River Forest, IL
River North, Chicago, IL
Roscoe Village, Chicago, IL
Schererville, IN
Skokie, IL
West Loop, Chicago, 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: