WP E-Signature by Approve Me - Sign Documents Using WordPress -

MEDICAL RECORDS REQUEST BY NEW PRACTICE

(takes up to 48 hours to process)

Date of Request:

PATIENT INFORMATION:

Name of Individual Completing Request:

Patient Name: Date of Birth:

Guardian Name (If applicable):

Phone Number:

NEW PRACTICE INFORMATION (where forms will be sent):

Name of Practice:

Provider Name:

Practice Address (to send records to):

Purpose:

Medical Care

Insurance

Personal

Other:

INFORMATION TO BE RELEASED:

Entire Medical Record

Dates

Other

Dates

Date:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

November 11, 2025 11:57 am MST

MEDICAL RECORDS REQUEST BY NEW PRACTICE Uploaded by Dermatology Partners Inc - info@dermpartner.com IP 181.16.19.132