Request Medical Records

Account #:

Patient Name:

Date Of Birth:

Phone:

Physician:

I authorize and request that you release my records to:

We will contact you when your Medical Records are ready. Best contact:

Phone:

Email:

Please mark which you are requesting:

A complete history/record concerning my illness and treatment.
 Yes No

A complete history/record concerning my illness and treatment during the period
 Yes No

Copy of x-rays on a disc (cost per disc $5).
 Yes No

Requests cannot be processed until the patient has signed the form and the form is received in our office by fax or mail.

Signature: ____________________________________________________________________

Fax Number: 801-314-4015

Mailing Address:
5848 S Fashion Blvd Ste 110
Salt Lake City, Ut 84107-6141

Special direction: “We need an actual patient signature, so print and sign then fax, scan, email or print and mail to us”.