Records Request

To request the release of your ZoomCare medical records please complete the Records Request form below. Please allow 2-3 business days for ZoomCare to process this request.

Patient First Name
Patient Last Name:
Street
City
State
Zip
Date of Birth (dd/mm/yyyy)
/ /
Age
Phone Number
- -



Please select the type of records your are requesting

ALL Records

Records for the following dates (dd/mm/yyyy)

/ / to / /


Records concerning the following issue only
(i.e. ankle injury, headaches)


Note: Laboratory testing and diagnostic imaging reports will be automatically included in records requests. Reports from referring providers, specialists, and physical therapists will not be included and must be requested from directly from those providers.


Records to be sent via
mail
fax
email

First Name
Last Name
Street
City
State
Zip
Fax
- -
Email
Email Confirm
Relationship to patient (choose one)
self
parent/guardian
other:

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