病历记录

通过安全表单并经身份验证申请病历记录。

本页面仅用于申请病历记录。不适用于新出现的症状、处方、治疗相关问题或紧急情况。

Records request

Verify your identity, then request your records.

Start by verifying your identity with an email code. After that, the records request stays inside this secure form instead of being sent through ordinary email.

Step 1

Verify your identity

Enter your full name, date of birth, and email. We will send a short verification code to that email before you can send the records request.

Full nameDate of birthEmail

Step 2

Describe the records you need

Phone (optional)

This request is for your own records only. If you are a personal representative or authorized requester, please contact admin@quickvisitmd.com with authorization documentation.

Your records will be delivered through the secure patient portal. You will receive an access code by email when they are ready.

Request date

What records are you requesting?Typed signature

Release notice

I understand the practice may still need identity or authorization review before records are released.

提交前须知

本页面仅用于申请病历记录
在提交申请前，需先通过发送至电子邮箱的验证码完成身份验证
申请将保留在安全的网站系统内，而非通过普通邮件发送

行政事务联系方式

通过安全表单并经身份验证申请病历记录。

Verify your identity, then request your records.

Verify your identity

Describe the records you need

使用网站遇到问题？