Medical Records Request

Please complete the below form below.

Our Medical Records team will reply to you with a secure email.

When you receive that email, you can reply to it and upload this Medical Records Authorization Form once you have completed your information.

Thank you.






This form should not be used to send sensitive information.

Completing this form does not secure an appointment please wait for a follow up email/phone call to confirm date and time.

Please do not include any private or medical information, as this is not a secured form.