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Patient Request for CD Medical Records
Please fill this out if you are a patient requesting a CD. Your report, if available, will be included with the CD. If you would like to come in person to request your CD, you do not need to fill out this form.
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* Indicates required question
Patient's First Name
*
Your answer
Patient's Last Name
*
Your answer
Patient's Date of Birth
*
MM
/
DD
/
YYYY
Person filling out this form
*
Patient (self)
Parent or guardian of the patient
Other:
Which exams are you requesting on the CD?
*
MRI
CT
Ultrasound
Xray
Mammogram
Other:
Required
Date(s) of exams that you are requesting
*
Your answer
How will you retrieve the CD?
*
Elk Grove Village pickup
Bedford Park pickup
Melrose Park pickup
Wheaton pickup
Darien pickup
Villa Park pickup
Mailed to me-- provide address below
Other:
Address to mail records (if mailing)
Your answer
Notes
Your answer
Number of copies requested
*
1 copy ($5 if picking up, $15 if mailed)
2 copies ($10 if picking up, $30 if mailed)
3 copies ($15 if picking up, $45 if mailed)
I certify that I am the above patient (or the patient's parent/legal guardian).
*
Yes, I certify
Type your name here to certify
*
Your answer
Your relationship to patient
*
Self
Other:
Cell phone number to contact with questions. We will message you when your records are ready.
*
Your answer
Click Submit below to proceed to the next page for payment please.
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