Patients

Medical records request.

Name: North County Orthopedic Medical Group
Address: 8929 University Center Ln, Ste 100, San Diego, CA, 92122, US
Telephone: (858) 457-4040
Price range: $$

Request a copy of your records or authorize release to another provider or party.

Call (858) 457-4040 All forms

Patient name *

Date of birth *

Phone *

Email *

Mailing address *

Records from (provider / practice) *

Records from date

Records to date

Records requested *

Purpose *

Send records to *

Recipient name

Recipient fax

Recipient email

Recipient address

Additional instructions

I authorize North County Orthopedic Medical Group to release the records described above.

Electronic signature (type full legal name) *

I agree to receive emails from North County Orthopedic Medical Group about my request (confirmations and follow-up).I agree to receive text messages from North County Orthopedic Medical Group about my request. Msg & data rates may apply. Reply STOP to opt out.

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