Request form for medical records

*Attach a photocopy of the patient’s identity card to this form in order to receive the requested information
*If you are requesting medical documents for another patient, attach a photocopy of the identity card and power of attorney with the full name and signature
*If you are requesting medical information for a deceased patient, attach an inheritance order/will/form for heirs, power of attorney from the heirs and a photocopy of the identity card of at least one of the heirs (If there is no power of attorney from the heirs signed in the presence of an attorney)
This service requires payment of a fee
Preparation of the medical information takes time and may take up to a month

Please fill out all fields marked with an asterisk *
Date (free text)
Department (free text)
Request for medical documents for:
Full name
Identity no.
Telephone (with option to receive SMS)
Name of the child for whom you are requesting the information
Select the requested information and mark “from date - to date”
Complete file – from date
Complete file – to date
Illness summary – from date
Illness summary – to date
Laboratory tests – from date
Laboratory tests – to date
Surgical report – from date
Surgical report – to date
Pathology results – from date
Pathology results – to date
Notice of birth – from date
Death certificate – to date
Other (free text)
Purpose of request
Receipt of documents