Email Medical Release Forms

We need an email release form before we can send you your medical records through a secure email link. There are three forms, download the most appropriate depending on what records you need. You will need to print and sign it and upload here as a PDF or image.

Once we receive the form, we can email you a secure link to download your records. You will need to type a password to download the file which will be your last name followed by the letters “jept”, e.g. “jonesjept” or “smithjept”.

Feel free to upload more than one form in multiple submissions if needed.

The three forms are: