Records Request
Form is only for Patients and Medical Providers involved in the care of the patient.

Lawyers, Insurances, and other entities must email a detailed request including a signed patient authorization when applicable to
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Email *
Your Name *
Relationship to the Patient *
Patient Name *
Patient DOB *
Let us know if you need all medical records we have or just a specific date or date range. *
How would you like to receive the records? *
Contact info for sending requested records *
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This form was created inside of AfterOurs Urgent Care.