Request Medical Records Southwest Kidney Institute Medical Records 5 Request Medical Records Requesting Physician InformationRequesting Physician Full Name(Required)Requesting Physician Phone(Required)Requesting Physician City(Required)Requesting Physician State(Required)Person Requesting RecordsPerson Requesting Full Name(Required)Person Requesting Email(Required) Person Requesting Phone(Required)Report Type(Required)Consult ReportLast Progress NoteCurrent LabsRenal Ultrasound ReportAll records (last 1 year)Patient InformationPatient Full Name(Required)Date of Birth(Required) MM slash DD slash YYYY Last four digits of Social Security #(Required)Please enter a number from 0 to 9999.Additional InformationHow would you like records sent(Required) Fax Email Would you like a follow-up e-mail?(Required) Yes No CommentsThis field is hidden when viewing the formPDF
