Required info*

		Please send the full electronic medical record for the following*
Payment Preference:*		Choose One Credit Card On-line Credit Card by Phone Check by USPS Mail Check by hand to the office
Contact Information: As it appears on your credit card, if paying by credit card.
First Name*
Initial
Last Name*
Address1
Address2
City
State		Zip
Email*
Phone*
Birthdate of the Patient*	Select One January February March April May June July August September October November December / Select One 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Select One 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Required to verify patient requesting the records.
Patient Names, if children or spouse:
Enter Total Check Amount	$  ($19 per patient name)
Credit Card Payment On-line:  only needed if this is your preferred method of payment, otherwise, leave blank. Credit card type Visa  Mastercard
Credit card# Exp. date Enter Total Credit Card Amount $ ($19 per patient name) You will receive a confirmation email from us.  To ensure delivery to your inbox (not junk, bulk or spam boxes), please add our domain name www.familycaresw.com to your e-mail Address Book.

 Press Submit button to complete your order

If you need assistance you may contact the Medical Records On-line Administrator by email  

Dear Patients,

This online service allows you to order your complete electronic Medical Record via the secure form -- in addition to calling, mailing or coming to the office, of course.

Full Electronic Medical Record : $19 per request, per patient. The full record consists of what we currently have on file electronically and not the older paper records prior to our computerized operations.

Your full electronic record will be generated and available to view approximately five (5) business days from your request. You will receive an email alert when it's ready for you to view.

Note: Each time you request your full medical record, we generate the latest data -- hence each future request would be $19.

Register for your secure On-line Patient Requests Account: If you haven't already done so, please REGISTER HERE for your Free On-line Account.  You must do this so you can Login to receive your electronic records. ONLY REGISTER ONCE. If you need help with your account you can email

Your on-line patient requests account gives you access to your EKGs, X-ray reports and Lab studies. You can also make an Appointment, request a Prescription refill and send a message to your doctor with Secure Mail.

Thank you,

FAMILY CARE SOUTHWEST, P.C.

Q&A:

What is the difference between Medical Records Online and ordering my Full Medical Records?

MEDICAL RECORDS & SECURE ONLINE PATIENT REQUESTS - FREE:

When you register for medical records on line, a secure summary of your chart as well as any recent EKGs, specialist consultations and lab reports will be uploaded and you will be able to view them on line.

FULL MEDICAL RECORD ONLINE $19:

For $19.00, you will receive a complete copy of your electronic medical record on line.

Note: Your paper chart will have information prior to the Practice going onto electronic medical records that will not be uploaded.