top of page


Release of Medical Record Form

If you are unable to view the form, you may click here to open it in a new window.

This form is utilized as permission to request or send medical records to any institution, free of charge. This includes but is not limited to other doctors offices, schools, and programs. We are not able to send a pdf document of your child's medical records directly to parents via email. You must request a MyChart account to securely access and download records. 

If you are changing pediatricians and transferring care, please notify our office to cancel any future appointments and clear any outstanding balances. 

bottom of page