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Records request

Complete this form to request a release of your therapy records. All submissions are sent directly and securely to the practice. Fields marked * are required.

Client information

Confirmation will be sent here

Records requested

Select all that apply

Send records to

Leave blank if records are for your personal use.

Additional notes

Authorization

Choose how you'd like to authorize this release.

Draw your signature in the box below

Submissions are sent directly to the practice. No PHI is stored on this server.