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
Relationship to the Patient
Primary Care Provider (PCP)
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?
Pick them up in Clinic
Contact info for sending requested records
Send me a copy of my responses.
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This form was created inside of AfterOurs Urgent Care.
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