Document Request Form

Select Physician

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Patient Details

Patient 1

First Name

Middle Name

Last Name

Phone

Email Your password and instructions to retrieve medical records will be sent to this email address.

Date of Birth

+ Add additional patient

Guardian Information

I, am the legal guardian for the above minor(s) (under the age of ) patient(s) of :

First Name

Last Name

Patient Address

Street Address

Apartment, suite, etc. (optional)

City

Province

Postal Code

How would you like to receive your medical records?

Transfer my medical records online

Transfer my medical records on a USB

Deliver To

To my email address (Note: Medical records will be delivered to the email address provided by each patient)

To my new doctor’s email address

To my home/mailing address

To my new doctor below

Name

Address

Apartment, suite, etc. (optional)

City

Province

Postal Code

New Doctor's Name

Doctor's Email Address

Doctor's Phone No.

Doctor's Address

Apartment, suite, etc. (optional)

City

Province

Postal Code

Declaration

I hereby direct and authorize [Selected Doctor’s Name] and DOCUdavit Solutions Inc. (“DOCUdavit”) to provide and/or transfer a copy of my Medical Records (or those of a minor of whom I am a legal guardian).

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Payment Summary

	Fee	Patients	Total

Have a promocode?

Choose Payment Option

Credit Card

Card Number

Expiry

CVD

Billing First Name

Billing Last Name

Billing Address

Billing City

Billing Province

Postal Code

E-transfer

Please e-transfer to medicalrecords@docudavit.com (Please include in message Patient 1 Full Name and former doctor's name)

Comments

Declaration

Please check your inbox to complete the authorization

We have sent a request to each patient’s email for signatures to complete the authorization. Please have them sign the authorization to continue.