Health Report Request Form - Lexington Pediatrics, PC

Health Form Request

Patient Information
Patient Name*
(mm/dd/yyyy)

Parent/Guarantor Information

How Would You Like The Report Delivered?
Please indicate below how you would like for the report to be delivered to you and fill in the associated field. We will contact you before we deliver this report.
	Hold at Lexington Pediatrics for pickup. PLEASE CALL BEFORE COMING IN TO PICK-UP HEALTH FORMS TO MAKE SURE IT IS READY.

	Confidential Fax

	Address
	City	State	ZIP

Confirmation
There is a $5 charge which you must pay before we deliver the report to you. You can pay the fee when you pick up the report from our office. Or, check this box and we will open a new window for you to pay the fee via PayPal when you click SUBMIT below.

Enter the characters you see below and click SUBMIT.

INSTRUCTIONS

Use this form to request a copy of your child's health form.
"*" shaded fields are required.

This report is provided to you during your child's annual check-up. If you use this form to request another copy of the report, there is a $5 fee that will be applied.

We strive to respond to your requests within 24-48 hours ( excluding weekends & holidays ).

After you have entered your information into this form, please click PRINT on your browser if you would like to keep a copy for your records.

Hit SUBMIT when you are finished.

KNOW MORE

Did you know that the state government sets the fee that you must pay when you request your health records?

Your name, home phone number and online information must match the information in our system in order for us to process this form.

When you are completing our online forms, items marked with an "*" are required fields. Make sure you enter your information into all fields that are marked with an asterisk.