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Request Records

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.*

Month

Day

Year

Phone*

Email*

Requested by

Relationship to Patient

Requested Record(s)

Test

Body Part

Study Date

Record(s) Delivery*

CD ($30 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*

Consent*

I authorize release of my medical records and/or diagnostic tests.*

Name

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

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