Enter Request Information
Upload Identification
Review and Submit

New Medical Records Request

Patient Medical Record Information

Patient First Name:

Patient Last Name:

Other Patient Names (Optional):

Patient Date of Birth:

Requested Information

NOTE: Physical Therapy (PT) records are NOT available via this request. To order PT records, contact Fred Weldon at (214) 220-2468 extension 1581.

SERVICE OPTION:

Include visits from today or yesterday? (May delay processing by 2 days)

Requestor Contact Information

Relationship to Patient:

Name:

Cell Phone Number:

Retype Cell Phone Number:

I cannot receive text messages at this phone number. (You will be contacted by email, which may add an additional 3 days of processing time.)

Delivery Method for Imaging CD(s)

Your imaging (X-Ray, MRI) CD will be mailed to your home address below. Please allow additional time for US Postal Service delivery after you receive the alert that your CD is ready. Delivery time required by the US Postal Service varies and is not the responsibility of Carrell Clinic.
NOTE: We cannot mail imaging CDs to any address other than your HOME address.

Please note: The Imaging CD you receive will contain images only (no reports). If you ordered Medical Records, they will delivered online to you.

Cancel

Continue

Are you sure you want to delete this request? This will stop all work on fulfillment and a new request will have to be entered.

Are you sure you want to cancel this request? The entered information will not be saved.

There has been an error processing your request. Technical support has been alerted, however additional information will help solve this issue. Please send some brief comments describing what you were doing:

Thank you for your comments. While waiting for technical support, please logout and log back in before retrying.