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El Camino Pediatrics:  Request for Medical Records

Medical Request Form for Previous Records
From: Another Facility
To: El Camino Pediatrics

Fill out and mail to your child's previous doctor

*Important: Original signatures are required, so faxed copies will not suffice.

EL CAMINO PEDIATRICS
477 N. El Camino Real, Suite B105
Encinitas, CA 92024
phone: 760-753-7143
fax: 760-753-2155

Date__________

Dear Dr. __________________________________


_________________________________________
Street Address

_________________________________________
City, State and Zip

Please forward copies of medical records including all reports and correspondence on the patients named below to El Camino Pediatrics at the above address.

Patient Name Date of Birth

Thank you.

_________________________________________
Signature of Parent or Guardian