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DOB
Month
Day
Year
How would you like the medical documents delivered?

*Please note that it can take up to 30 days to process records. If you need the records before the 30 days, please ensure that you have selected "Rushed Delivery" or "Expedited Delivery".

Requested By
Purpose

Please provide recipient info if other was selected above.

Ensure that the following is included:

Name/Title

Phone Number

Address

Email

Documents Being Requested
Today's Date
Month
Day
Year

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