• Medical Records Transfer Form

    (for established patients leaving our practice)

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  • 115 Norwood Park South, Suite 110, Norwood, MA 02062 

    (p): 781-769-4090, Fax: 781-769-6485

    122 Grove Street, Suite 203, Franklin, MA 02038 

    (p): 508-528-5404, Fax: 508-528-5383

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  • Please note: if you would like us to mail your records, there is a $15 shipping charge. You may call our office to make this payment over the phone, or use the PayPal widget below. 

    You may pick up your records in our office free of charge.

    We cannot fax your medical record.

    If you would like your records to be mailed your new doctor, please fill out the address information below, and call our office or use the PayPal widget below to submit the $15.

    If you are going to pick up your records in our office, you may leave the address information below blank.


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  • Note: When you hit submit, the form will take you to our PayPal page to complete payment. The PayPal page will ask you for a "donation". The donation format is the only one offered by the online form that will allow our patients to pay for records online. You are not actually making a donation to our practice.

  • By signing below, I indicate that I have read and understand all the information on this form. Any information that I have entered is, to the best of my ability, correct.

  • Please click the submit button to send to our office electronically

    OR

    print this form and bring it into the office.

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