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New Medical Records Request

Patient Medical Record Information

Patient First Name:

Patient Last Name:

Other Patient Names (Optional):

Patient Date of Birth:

Requested Information

Requested Records:

Include visits from today or yesterday? (May delay processing by 3 days)

Requestor Contact Information

Relationship to Patient:

Name:

Cell Phone Number:

Retype Cell Phone Number:

I cannot receive text messages at this phone number. (You will be contacted by email, which may add an additional 3 days of processing time.)

Delivery Method for Imaging CD(s)

Please select a delivery method for your imaging (X-Ray, MRI) CDs. For mailing, please allow an average of 7 additional business days.

CD Delivery Method:

Please note: The Imaging CDs you receive will contain images only. For CD pickup, please go to the MRI front desk at the Dallas clinic (Suite 100, first floor). For mailing, allow an additional 7-10 business days for delivery. If you ordered Medical Records, they will delivered online to you.

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