Medical Records Request

Request for Official Medical Records

This form authorizes the release of the following medical records to ensure comprehensive care and compliance with health and safety requirements: Annual Physical, Immunizations, Annual Screenings, Emergency Action Plans

Name student used while in school (e.g. maiden name of female student): *

First

Middle

Last

Date of birth of student: *

Last year in attendance at St. Stephen's: *

How should we send the medical records? *

Email
Pick up

Please provide, as applicable, specific delivery instructions, including the complete e-mail address where records are to be sent OR the complete address where records are to be mailed.

Full name of person completing this form: *

First

Middle

Last

Phone number of person completing this form: *

Email address of person completing this form: *

Electronic Signature *

ELECTRONIC SIGNATURE: Please type your full name below. I agree that my Electronic Signature on this form is the legal equivalent of my written signature. Electronic Signature means any electronic sound, symbol, or process attached to or logically associated with a record and executed and adopted by a party with the intent to sign such record pursuant to the Texas Uniform Electronic Transactions Act (Tex. Bus. & Com. Code Ann. § 322.001 et seq.) as amended from time to time.