1 Patient Info2 Organization Info3 Final Step Patient's First Name* First Patient's Middle Name Middle Patient's Last Name* Last Patient's Previous Nameseg. maiden names, nicknames, etc.Patient's Date of Birth*Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Patient's Personal Health Number (PHN)*ie. CareCard NumberPatient's Previous Doctor(s)* Name of doctor(s) that created patient's records. List all if more than one.File Number/Case Number Organization's Name*Organization's Phone Number*Organization's Email*We will send confirmation and your invoice via email Enter Email Confirm Email Organization's Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code File Processing Fee* Price: $ 1.00 CAD Total $ 0.00 CAD Credit Card*Your credit card will not be charged until the record transfer is complete. There is a $26.25 charge per request. Total charges depend on the size and type of the record. Taxes and Shipping are not included. An invoice will be e-mailed to you. American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date CVV Cardholder Name No Credit Card We do not have a Credit Card *** Please note a credit card is required for the quickest transfer of medical records.Send Cheque*We understand the necessity for a Credit Card, but we still wish to proceed with the transfer of the medical records. We understand that without a credit card, this process is delayed and the process is not complete until MedRecords receives a cheque of $26.25 for the request. Please send cheque to: MedRecords Distribution Association PO Box 999 Stn. Main Port Coquitlam, B.C. V3B 6H9 We agree with the above and will send in a cheque immediately Patient Authorization for Release of Information.*Please upload the patient's authorization form in PDF, jpg or png format. A patient's signature is required or court ordered authorization. If you are submitting a notice of application, DO NOT FILL OUT THIS FORM. Please email notice to email@example.comAccepted file types: pdf, jpg, png, jpeg.Certified True Copies ($45)*A certified true copies signifies that the records have not been tampered or altered with. This is used for medical legal purposes and can be used in a court of law. MedRecords' certified true copies ensures that each CD is unalterable and marked with a legal certification to signify the CD is a certified true copy. The fee for certified true copies is $45. Non-certified copies are watermarked to reflect this. Yes, we would like to have certified true copies.No, we do not want certified true copies.**NOTICE: These records have been provided for clinic use only. Readers are cautioned that these records may not be suitable for their purpose. They are watermarked to reflect this. This may cause issues when printing.Rush Order ($200)*Rush orders are prioritized first and do not wait in the request queue. Once processing is complete, the records are shipped as a priority. There is an additional flat fee of $200 per record. This is the fastest way of obtaining a copy of a medical record, otherwise this can take up to 45 business days depending on the queue.Yes, we would like to have this request rushed.No, we would not like to have this request rushed.Terms and Conditions* We agree to the Terms and Conditions. Service Charge* We understand that there is a charge for this service.