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Request for Medical Information
This template form allows you to request medical information from previous providers. With sections for medical history such as vaccinations, surgeries, treatments, etc this form may be customized in Word format to meet the needs of your Doctor Office when it comes to requesting or providing a patient's medical information.

Free Sample Template
Format: Word PDF
# of Pages: 1
Printable: Yes

Request for Medical Information TemplateForm 2788
Format: Word PDF
Category: Medical, Doctor Office
Type: Request

Request for Medical Information

Doctor’s Name: ________________________________________________________________________________

Address: ______________________________________________________________________________________

City: _____________________________________ State: _____________ Zip Code: _________________________

Phone Number: ________________________________________________________________________________

Email Address: _________________________________________________________________________________

Pharmacy Name: _______________________________________________________________________________

Pharmacy Phone Number: ________________________________________________________________________

Current & Past Medications

Name

Dosage

Frequency

Start Date

End Date

Doctor

Reason

Surgical Procedures

Date

Procedure

Doctor

Hospital

Notes

Major Illness

Illness

Start Date

End Date

Doctor

Notes

Vaccinations

Name

Date

Name

Date