INSTRUCTIONS: 

Below and on the next page are the forms for your Personal Health Profile.  Those fields in red, must be fill out so we can read your contact information.  We do not retain any information on line.  Once you complete the form and hit the print button, all information that you input will be discarded and your only copy will be the forms you print. When you fill out and print the next form, Your Patient Medical History And Questionnaire, a pre-addressed shipping label will also be printed so you can send copies of your medical records to us.

Once the forms have been printed, contact your Doctor(s) and request copies of your medical reports.  Once received from your doctor, please place your records (in the order you want them displayed) in an envelope, place the proper postage on the envelope, then paste our pre-addressed shipping label on the envelop, and then mail your records to us.  Your Medical Record CD will be mailed within 4 weeks from the date we received your records in our office.

MRTAuth
  AUTHORIZATION
Print in block letters in BLACK if you do not fill in the form on the computer >    JOHN SMITH 
Fields labeled in RED* are required to be completed.
PERSONAL INFORMATION
NAME*         
FIRST M.I. LAST
DATE OF BIRTH                    SS#  
MONTH DAY YEAR
HOME ADDRESS*   
CITY*     STATE*     ZIP*  
HOME PHONE*             WORK PHONE  
E-MAIL ADDRESS*   
PHYSICIAN             BLOOD TYPE  
ALLERGIC TO  
EMERGENCY CONTACT  
EMERGENCY CONTACT PHONE NUMBER  
HEALTH INSURER             TEL. #    
ID#             GROUP#   
GROUP NAME   
POLICY HOLDER NAME   
RELATIONSHIP TO POLICY HOLDER  
Phone Number : 561 - 488 - 0908
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