This form is only to request your child’s medical records FROM Woodinville Pediatrics. It is not for requesting records from the previous provider to send TO Woodinville Pediatrics. That form is here. You will receive an emailed copy of this form. We will copy the records to a CD.

You must submit one form for each child.

We must have appropriate signature(s).

Signature of Patient (18 years or older) or Legally Responsible Party (Parent or Guardian)

Signature of Minor Patient (Ages 13-17) Required for Certain Records: a minor patient’s signature is required to release the following information: 1) Information related to reproductive care such as birth control, pregnancy-related services (all ages) 2) Sexually Transmitted Diseases, including HIV/AIDS (age 14 and older); 3) Substance abuse and mental health treatment (age 13 and older).