MEDICAL RECORDS REQUEST

MEDICAL RECORDS REQUEST
Date*

MonthDayYear
Date
Dear Doctor or Hospital Staff:

I hereby request from Dr.
Name*

First NameLast Name
Phone*
Fax*
Please forward a copy of my medical records to the practice below.*

Most recent history and physicalMost recent lab testsMost recent chest x-rayMost recent EKGOther
P.O Box 34422 Bethesda, MD 20827

Phone number: (240)-449-3094

Fax: (240)-489-4415
Name*

First NameMiddle Name / MILast Name
Date of Birth*

MonthDayYear
Date
If there are any charges for having the records sent, please contact the following person to arrange payment.
Contact Name
Contact Phone Number
Please enter a valid phone number.
Signature of Patient or Power of Attorney*

Clear
Name

First NameMiddle Name /Last Name
Name of Power of Attorney
Should be Empty: