Physicians
Services
Office Policies
Appointment Request
Forms
	New Patient Forms
	Medical Records Request
	Request to Transfer / Copy / Inspect Medical Records
	Update Contact and Insurance Information
	Health History Questionnaire
	Vaccine Designee Consent Form
	Consent for Treatment by Designated Guardian
	Other Forms
Billing & Insurance
Patient Education
Relay Health
Links
Site Map

Forms - Medical Records Request

If your child was followed by another pediatrician before coming to our practice, it is important to get your child's prior medical records in order for us to provide the best possible care.  To request medical records from another pediatrician or practice:

1. Click on the link to open the PDF file (below)
2. Print the form
3. Fill out the the requested information
4. Sign the form
5. Either mail or fax the form to your child's previous pediatrician

This authorization allows us to obtain your child's prior medical records, including growth curves and immunizations.

To complete the request form, please download and print this document:

Authorization to Release Medical Records To South East Bay Pediatrics