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Request Duplicate Medical Records

The cost of your duplicate medical records is $19.99. Once we have received your request, your duplicate records will be emailed to you within 1-2 business days.

Payment Method :

Amount :

First Name:

Last Name:

Birthdate:

Phone Number:

Fax Number:

Location :

E-mail Address:

Note: Please use the same email that you provided on the computer registration in the office. e7 Health can only utilize this email to send patient information. If you are unable to use this email, the duplicate records must be picked up in person with a Photo ID.

What duplicate records do you need? Note: Please specify (TB Test, Lab Results, Vaccine Record, Physical Exam, etc.)

Street Address :

City :

State :

Zip :

Country :

Card Type :

Credit Card # :

Expiration Month :

Expiration Year :

CVV2:

Street Address :

City :

State :

Zip :

Country :

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