Medical Records Request

We store all of your information in our medical records department, which is located at 3535 Quakerbridge Road, Suite 300, Hamilton, NJ 08619. Our film pick-up hours are Monday through Thursday from 8:00am to 7:00pm and Friday from 8:00am to 5:00pm. Should you ever need to pick up your medical records, please call 609-890-0033 x6231 or email us via the form below.

Patient First Name:

Patient Last Name:

Address:

City:

State:

Zip:

Date of Birth:

Parent / Spouse Name: *

Daytime Phone Number:

Cell Phone Number: *

Evening Phone Number:

Patient Status:

Type of Study:

Date Study Performed:

Date Needed for Pick-Up:

Any additional information you need to provide? Please do so here: *

Terms and Conditions

I hereby relieve Quakerbridge Radiology from any legal liability that may arise from the release of the studies requested. I understand that the above studies are part of the permanent medical of Quakerbridge Radiology and will safeguard them and shall be fully responsible for them until they have been returned to Quakerbridge Radiology.

I also understand that the above studies must be returned when the physician/agency is through with them. The only exceptions will be for CT and MRI studies, which will be kept by the patient and not returned. However, if the studies are lost or misplaced, there is a $35.00 fee for Quakerbridge Radiology to reproduce these studies.

I have read and agree to all the terms above.

* denotes optional form field