Record Request

If you want to receive a copy of your child’s records, please complete the form below. A member of our team will contact you if there are any questions. Please allow 7-10 days for your request to be processed.

Record Release Request

"*" indicates required fields

This field is hidden when viewing the form

Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.

Your Name*

Parent First Name Parent Last Name

Patient Name*

Child's First Name Child's Last Name

Your Address

Street Address Address Line 2 City ZIP Code

Service Location*

Preferred Method of Contact

Your Email Address*

Email Address Confirm Email Address

Your Phone*

Untitled

Comments

This field is for validation purposes and should be left unchanged.