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Record Request Form

Please fill out this form prior to your visit!

Complete this form today to authorize the transfer of your medical records from your existing medical provider. Thank you!

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Authorization for the Release of Medical Information

Please release my protected health information for the purpose of orthotics evaluation and treatment to:

My Foot Rx • 1706 York Street, Suite 3 • Bloomer, WI 54724
Phone: (715) 568-1500 • Fax: (715) 568-1501

* Indicates A Required Field

Patient Information

Patient Name *

M.I.

Last Name *

Address *

City *

State *

Zip *

Email Address *

Phone Number *

Today's Date *

Date of Birth

Comments

Facility Information

Facility or Physician Name*

Address *

City *

State *

Zip *

Facility Phone Number *

Captcha Code

Signature *

Please type your first and last name

I understand that checking this box constitutes a legal signature confirming that I authorize the release of my medical records to the facility listed above.