Medical Records Request printable pdf download

Medical Records Request

Tom’s Tonics-A Modern Apothecary, LLC

Dr. Thomas J. Francescott

Naturopathic Health Care

MEDICAL RECORDS REQUEST

Please fill-in the name of the physician, hospital, or clinic you are requesting

info from:

To:

Name

________________________________

Street

________________________________

City/Zip

________________________________

Fax

________________________________

Re:

Pt. Name ________________________________

DOB

________________________________

The above patient is under the care of Dr. Thomas J. Francescott,ND. Please

forward the following information as soon as possible:

(PLEASE FAX TO 845-876-5559)

___ Laboratory work

___ X-rays, CT scans, MRI, any other imaging studies

___ Other_________________________

For Time period: _______________________

I hereby authorize _____________________(see above) to furnish the

above requested information contained in my medical record to Tom’s

Tonics-A Modern Apothecary.

Signature: _____________________________

Date: ______________

Tomʼs Tonics-A Modern Apothecary

6384 Mill Street

Rhinebeck, NY 12572

Phone: 845-876-5556

Fax: 845-876-5559

web:

Medical Records Request