Request Records | Eisenhower Imaging Center

How to request medical records

To request medical records, please call 760.674.3876 or fill out the form below.

"*" indicates required fields

Patient First Name*

Patient Last Name*

D.O.B.*

Phone*

Email*

Requested by

Relationship to Patient

Requested Record(s)

Test

Body Part

Study Date

Record(s) Delivery*

CD ($10 each - No Cash)

Electronic Medical Records (free)

Report (free)

CD Delivery*

Pickup Location*

Address*

Street Address Address Line 2 City State ZIP Code

EMR Delivery*

AMBRA Email*

Power Share - Facility Name*

Life Image - Facility Name*

Fax Report to*

Name

This field is for validation purposes and should be left unchanged.

To request medical records, please call 760.674.3876 or download and complete the form below and fax to our medical records department.