Request of Records
Please fill out the form below to request your records from Planned Parenthood of Western PA. Please note that this form may only be filled out by the patient. By filling out this form, you acknowledge that staff may contact you to clarify or ask more information regarding your request. If at all possible, please use the email address and phone number that you provided during your appointment. To update your email address and phone number, please call 412-434-8971.
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Email *
Patient's Full Legal Name *
Patient's Date of Birth *
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Patient's Home Address *
Patient's Phone Number *
Who would you like records released to? *
In order to ensure that you are the person to whom the medical record belongs, please answer the following questions.
Who is your PPWP emergency contact? *
On what date were you last seen at PPWP, approximately? *
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