Medical Records Request Form

Customize template

Quickly and effortlessly optimize this medical records request sample, as our platform provides a variety of intuitive tools and multiple customization features. Play around with drag and drop to add, remove or rearrange fields, upload a logo, change the design theme and configure multiple email recipients for your form.

Publish template

Patients will be able to request medical records even from their mobile devices since our web forms are mobile-friendly. Share with them this medical records request form by simply copying and pasting the form code in a web page. Clicking the social media buttons on our platform lets you instantly publish the form on a social media page.

Collect & manage data

Managing sensitive healthcare information is no hassle with our secure medical records request form. Patient submissions are streamlined over a SSL connection and safely kept in an encrypted repository. With just a few clicks, you can make your medical forms HIPAA compliant as well. Manage all the data directly on our platform, export them on your preferred device or connect with third-party web apps.

Optimize processes

Improve your medical facility’s workflow with online medical forms that help both patients and doctors. Set up email notifications to receive alerts whenever a patient submits a medical records request. Automating your data collection with 123 Form Builder will significantly simplify your administrative work and save you time.