Attorney Records Release

Please complete the form below or download the pdf and fax the document to 480-949-2091. DOWNLOAD PDF >>

Date
Date Format: MM slash DD slash YYYY
RE: Patient (Full Name)*
Date of Birth*
MM
DD
YYYY
- Phone
- FAX
Email
Consent*
There is a $50 charge for medical records; we will remit records after receiving payment.
Scottsdale Infectious Diseases Tax ID 200866190
Signature
Name
This field is for validation purposes and should be left unchanged.