[OUTDATED] Patient Record Request

[Percival Pigeoner]

Los Santos Emergency Services

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PATIENT RECORD REQUEST

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I. Name of Patient: FNAME LNAME
II. Date of Request: DD/MM/YYYY
III. Copy request of the following: Check at least ONE (1)
　　[ ] Patient File / Recent Check Up
　　[ ] Laboratory Test
　　[ ] Autopsy
　　[ ] Narrative Summary
　　[ ] Death Certificate
　　[ ] Body Diagram

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I. Sent to: FNAME LNAME
II. Contract Address/Email: ANSWER
III. Reason for Request / Warrant Proof: ANSWER
IV. Association of Requesting Party: Check ONE (1)
　　[ ] Family
　　[ ] Beneficiary
　　[ ] Los Santos Police Department [NEED A WARRANT]
　　[ ] San Andreas Sheriffs Department [NEED A WARRANT]
　　[ ] Department of Justice [NEED A WARRANT]

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Additional Notes: ANSWER

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Signature:
FNAME LNAME ((or image))
DD/MM/YYYY

E-Mail the format to the Director of Clinical Operations e-mail account below:

Director of Clinical Operations (CLICK HERE)

Code: Select all

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[font=arial][size=180][b]Los Santos Emergency Services[/b][/size]
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[center][size=150][color=red][b]PATIENT RECORD REQUEST[/b][/color][/size][/center]

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[b]I. Name of Patient:[/b] FNAME LNAME
[b]II. Date of Request:[/b] DD/MM/YYYY
[b]III. Copy request of the following:[/b][i][size=85] Check at least ONE (1)[/size][/i]
　　[ ] Patient File / Recent Check Up
　　[ ] Laboratory Test
　　[ ] Autopsy
　　[ ] Narrative Summary
　　[ ] Death Certificate
　　[ ] Body Diagram
[hr][/hr]
[b]I. Sent to:[/b] FNAME LNAME
[b]II. Contract Address/Email:[/b] ANSWER
[b]III. Reason for Request / Warrant Proof:[/b] ANSWER
[b]IV. Association of Requesting Party:[/b][i][size=85] Check ONE (1)[/size][/i]
　　[ ] Family
　　[ ] Beneficiary
　　[ ] Los Santos Police Department [b][i][NEED A WARRANT][/i][/b]
　　[ ] San Andreas Sheriffs Department [b][i][NEED A WARRANT][/i][/b]
　　[ ] Department of Justice [b][i][NEED A WARRANT][/i][/b]

[hr][/hr]
[divbox=white][b]Additional Notes:[/b] ANSWER
[/divbox]
[hr][/hr]
[b]Signature:[/b]
[i]FNAME LNAME[/i] ((or image))
DD/MM/YYYY
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[img]https://i.imgur.com/JU01ZAV.png[/img]
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[Emi Winter]

This form is now outdated, please refer to the main form to submit.

To Staff: Please refer to the incoming request section and process as needed.