Medical Reports

Please fill out the Medical Reports Form below. We typically respond within an hour.

Medical Images Request Form

First Name *

Last Name

Phone *

Email *

Date of birth

Who will receive your report? (choose only one) *

Only myself

My medical provider

Both myself and my provider

How will your medical provider receive your report? *

Fax

How will you (patient) receive your images (choose only one) *

Mail

Pick up in office (by appointment only)

Doctor's Fax or email address: *

Your email address: *

Please upload a Photo ID

I do hereby consent to authorize Healthy Heart Imaging / Atlanta Ultrasound to release copies of my images and medical records to the named parties on this form.

Please sign below *

Clear