Skip to primary navigation
Skip to main content
Skip to footer navigation

Request an Appointment
Bill Pay
Contact Us

Services
Locations
Team
Patients
Referring Physicians
- Request Records
- Exam Preparation
About Us

Coachella Valley

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.*

Comments

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

About Us
Services
Locations
Patients
Referring Physicians
Career Opportunities
Contact Us
Request an Appointment
HIPAA Regulations
Privacy Policy
Legal Disclaimer

You are now leaving the Eisenhower Imaging Center website.

When leaving the Eisenhower Imaging Center website via a hyperlink to a third-party website, it is strongly recommended you review the contents, privacy statements and disclaimers of every website you visit. Eisenhower Imaging Center has no control over the contents of such sites and is not responsible for either the privacy policies of other websites or the validity of any information or services or products provided therein. Any hyperlink to an external website does not indicate in any manner Eisenhower Imaging Center's sponsorship or endorsement of, or affiliation with, that website. Such links are provided for your convenience only.