Medical Records Request Form

We are committed to ensuring a smooth and efficient process to fulfill your request. To expedite this process, please complete each field in the attached request form accurately.

Our team may reach out to you for clarification or verification of the details you provide to ensure the accuracy of your request. This helps us safeguard your privacy and guarantee that your records are sent to the correct recipient.

Please note, we will make every effort to provide you with your requested medical records as promptly as possible. You can expect to receive your records no later than 15 days from the date of your request.

If you have any questions or require further assistance, please do not hesitate to contact us at 844.585.3544.

Sign in to Google to save your progress. Learn more
Name of Requester (Parent/Guardian, Self, Physician, etc.)   *
Patient First Name *
Patient Last Name  *
Patient Date of Birth *
Patient Phone Number *
Email Address *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Citra Urgent Care. Report Abuse