Medical Records Request

Medical Records Request

by Patient or Guardian
Patient's Name*

First NameLast Name
DOB*

MonthDayYear
Date
Contact Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*

First NameLast Name
Relationship to Patient*
(i.e. mother)
Payment

Please call our office at (512) 478-8116 to process payment and complete your request.
Medical Records Requested*

Office Visits ($10)X-Rays ($10)Office Visits + X-Rays ($20)
Beginning Treatment Date*

MonthDayYear
Ending Treatment Date*

MonthDayYear
I request the records be provided to me:*

Electronically (on a CD)Paper copy
I would like the records delivered to me by:*

USPS mail ($1.75)I will pick upI will have someone pickup my recordsOther
Person picking up my records (if applicable)
Please specify who
By signing this form, I understand that the information in the record may include personal, sensitive information. I also understand and accept full responsibility for the medical records I am about to receive and I relinquish CTPO of any and all accountabilities concerning these medical records.
Signature*

Clear
Today's Date*

MonthDayYear
*If you are picking up records, please make sure to bring a valid ID.

Please call our office at (512) 478-8116 to complete payment and process your request.
Should be Empty:

Payment