Medical Records Request Form
This form is for old MAIA students (alumni) who have lost their medical immunization records. All MAIA students receive their medical records when they leave. If you need another copy of your medical forms, follow these steps:

1) Pay service fee on this website: https://squareup.com/market/maia-medical-records
- Pay $10 for delivery by mail.
2) Submit this form
3) Wait 7-10 business days
Email address *
How would you like to receive your records? *
Bring valid photo ID if you are picking up your records at MAIA. Email the nurse, ana.k@maia.edu 48 hours before your arrival so that someone will be ready to assist you.
Family Name (Passport) *
Your answer
First Name (Passport) *
Your answer
English Name *
Your answer
What University are you attending? *
Your answer
What year did you graduate MAIA?
Your answer
Mailing Address
Your documents will be sent to this address only (if selected). PLEASE make sure that this address is correct.
Street *
Your answer
City/Town *
Your answer
State *
Your answer
Zip Code *
Your answer
Billing Information
Provider's Name (If sending to University or Doctor's Office)
Your answer
Provider's Address
Provider's Fax # or Secure E-mail
Your answer
Square Receipt Number (Find this by completing Step 1) *If you will come to MAIA to pick up your documents, please write "N/A" here* *
Your answer
Submit
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