Patient Medical Record Request Form

Who needs your medical records? *

Personal
Provider
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First Name *

Last Name *

Phone *

Date of birth *

Specify Requirements *

How would you like to receive your records? *

Mail
E-mail
Fax
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How do you like to send the records? *

Fax
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Email *

Fax Number *

Mailing Address *

Date Range:

From *

Till *

Message

I agree to the privacy policy provided by South Lake Gastroenterology. By providing my phone number, I agree to receive text messages.