Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Premier Orthopedics, P.A.

Medical Records Request

Please complete form to receive patient medical records. Please also indicate your preferred delivery method.

* indicates required field
  Name
please provide name of requester
  Phone Number
  Preferred Delivery Method
  Additional Details
If Fax: please provide Fax Number
If Mail: please provide complete Mailing Address
If Pickup: please provide name of person picking up records.
Patient #1
* Name
* Date of Birth
* Date of Injury
  Patient Account #
please provide if available
* Visit Date
please indicate "All" or list specific dates.
* Records Location
location of patient treatment
Patient #2
  Name
  Date of Birth
  Date of Injury
  Patient Account #
please provide if available
  Visit Date
please indicate "All" or list specific dates.
  Records Location
location of patient treatment
Patient #3
  Name
  Date of Birth
  Date of Injury
  Patient Account #
please provide if available
  Visit Date
  Records Location
location of patient treatment
Patient #4
  Name
  Date of Birth
  Date of Injury
  Patient Account #
please provide if available
  Visit Date
  Records Location
location of patient treatment