MedChart - The Peterborough Clinic

Before we begin,

We need to know whose consents we're collecting.

Client Type *

SDM Type *

First Name *

Middle Name

Last Name *

Relationship to client *

Contact Email *

SDM Document *

Patient Information

Welcome to The Peterborough Clinic - Medical Records's release of information process. Please complete the following steps to submit your request.

First Name *

Last Name *

Province *

Date of Birth (YYYY-MM-DD) *

Patient Email *

Phone

Not submitting a healthcard number may result in your request taking longer than usual or risking rejection.

Health Card Province

Health Card Number

Please ensure that all information submitted here matches the patient's health card. Providing information that does not match the health card will incur slower processing and the possible rejection of the request.

Request Details

Please indicate the date range and records you are requesting.

Please ensure this information is correct.

Start Date

End Date *

Please select what types of records you would like to order from The Peterborough Clinic - Medical Records.

Available Products

Records / CNRs

Select a provider

The Personal Health Information Protection Act (PHIPA) protects the privacy of your personal health information, including information about you maintained by The Peterborough Clinic and provides you with certain rights and choices about how this information is used and disclosed. As a custodian of your personal health information, our organization is required to comply with this legislation. For any questions regarding the request process please send an email to Medchart at clinic@medchart.ca

Before we begin,

Patient Information

Request Details

Information Summary

Request and Invoice Summary

Total: $

Authorization and Documents

Payment Information

Total: $