Please complete the fields below to request your or your child's medical records sent to yourself. NOTE: We can only send the records to the email or mailing address we have in your medical chart.

    If you need your records sent to a 3rd party (another physician or business), please call the office at 212-334-3774.

    Patient First Name *

    Patient Last Name *

    Patient Date of Birth * (mm/dd/yyyy)

    My Relationship to Patient*
    SelfParent/Guardian Name:

    Phone *

    Email *

    Confirm Email *

    How would you like your records sent? * (Choose One)

    Email to my address above: I understand there are security risks associated with email and that my information could be read or accessed by a 3rd party while in transitEncrypted Email to my address above: I understand that I will have to create a login/password to receive my records and that my information could be read or accessed once it leaves the encrypted mail systemUSPS Mail to my address:

    *I confirm that the email or mailing address above is the information in my medical chart.

    By clicking Send, you are initiating an email to Tribeca Skin Center. Email is not a secure form of communication.