Patient Records Request Form

To support our patients in the event that they outgrow us or move out of our reach, we will send patient records to other offices.

You must include the names and dates of birth for ALL applicable patients, and must include the name of the new doctor and their office’s information in the boxes below.

By submitting your information, you’re giving us permission to send your medical records to a new doctor and to contact you for more information if necessary.

We reserve the right not to process requests that are missing crucial details.

Records requests coming from lawyers, lawyers’ offices, or representatives thereof will be ignored if not submitted through the proper channels.