Medical Record Request Form printable pdf download

Medical Record Request Form

Student information:

(Please Print)

Last name while attending Leyden: _________________________________________

First name: ____________________________________________________________

Last name (current): _____________________________________________________

Birthdate: _____________________________________________________________

Phone number: _________________________________________________________

Email: ________________________________________________________________

Date of graduation or last year attended: _____________________________________

Campus (circle campus attended)

East or West or other____________________

Address to mail health record to:

Name: ________________________________________________________________

Institution: ______________________________________________________________

Address: ______________________________________________________________

City: _______________________________________ State:________ Zip: _________

Email: ______________________________________ Fax: ______________________

Records can also be picked up in the health office during school hours.

Remember: A copy of your driver’s license or state ID is required

Signature: ________________________________________________ Date: ________

I authorize Leyden High Schools to release my medical records to the above recipient.

Medical Record Request Form