Name
First Name
Last Name
Name 2
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Records _____ Eastland
To
From
Please select if records are to be sent TO or FROM Eastland Lifestyle Center
Records ____ Other
Previous / New Office
Name of the office for the exchange of records
Attention:
Ph:
Fax:
Approximate first visit:
-
Month
-
Day
Year
Date
Approximate last visit:
-
Month
-
Day
Year
Date
Records to be transferred:
XRay and MRI
Radiology Reports
Medication List
Chart Notes
Diagnostic Tests
Initial Consultation
Progress Notes
Care Plans
Complete Record
Other
Fax 2:
Ph 2:
Signed:
Date:
*
/
Month
/
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Signer's Relationship to Patient
Self
Mother
Father
Parent
Spouse
Grandparent
Legal Guardian
Name of signer
First Name
Last Name
Preview PDF
Submit
Should be Empty: