HRR Form | Citrus Medical Centre

PART 1: Patient Information

Patient's Full Name

Date of Birth

Year

Month

Day

Health Card # (if applicable)

To (Name of MD/Person/Facility)

Phone

Fax

Please select one of the two options:

Request

I consent to Citrus Medical releasing my medical records to the doctor, person, or facility indicated above

I consent to having my records sent to the doctor indicated below:

Please send the following:

(WE DO NOT ACCEPT CDs) & we use PS Suite if you want to export the chart

Send

Full Medical Chart

Specific Records (please specify below)

Other (please specify below)

Enter specific instructions/details here

Printed Name (Patient or Substitute Decision-Maker, if applicable)

Signature

Signature field is empty.

Draw, type, or upload a photo of your signature

Select if you would like to receive an emailed copy of your form submission