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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