Dialysis Access Center - Request Records

Physician Name (First & Last) *	Name of Person Requesting Records *
Office Number (Area code first, no spaces) *	Fax Number (Area code first, no spaces) *

E-mail Address *

Records Requested *

First Name *	Last Name *
Date of Birth (mm/dd/yyyy) *	Last four digits of Social Security # *

Please send the medical records by: *

Would you like a follow-up e-mail? *

Questions/Comments

* = Required Fields

Record Request Dialysis Access Center, Inc.