Request for medical records

Start of period(Required)

End of period(Required)

Documents I want to recieve:(Required)

Name(Required)

First Last

Personal Identity Code(Required)

Phone Number(Required)

Address(Required)

Street Address City ZIP / Postal Code

Delivery Method(Required)

By secure email to my email address

I wish to receive the information as copies sent to my address by registered mail.

I will collect the copies from the office.

By secure email to my email address

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