MedChart - Toronto Poly Clinic

SDM Type *

First Name *

Middle Name

Last Name *

Relationship to client *

Contact Email *

SDM Document *

Patient Information

Welcome to Toronto Poly Clinic '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.

Information Summary

Please review your submitted information. Ensure all submitted information is shown exactly as it appears on your health card.

Please confirm that all of the above information is correct prior to submitting your request.

Authorization and Documents

Please click "Continue" below to digitally sign and submit the required authorizations.

I agree to Medchart's terms and conditions and consent for them to use the information provided to retrieve medical records on my behalf.

Payment Information

Date Range
Attention Items

Item Type

Fee

Eletronic Fee: $

SubTotal: $

HST: $

Total: $

Credit Card Online

Cancel

Before we begin,

Patient Information

Request Details

Information Summary

Request and Invoice Summary

Total: $

Authorization and Documents

Payment Information

Total: $