REQUEST FOR MEDICAL RECORDS
Please use this form to request medical records from the SIL Clinic, Dallas Texas.  You can use this ONE form for multiple family members.
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Email *
Patient Name (Full Legal Name) *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Please include area code and/or country code if applicable

Time Period Requested (e.g., last 3 years)

 *
Information Requested (check all that apply): *
Required
Are you requesting records for additional people within your family? *
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