Medical Records Transfer FormPlease fill out and review the Records Transfer Form Download Form Here Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastD.O.B. *Date of Birth (xx/xx/xxxx)Please send information, including diagnosis and records of any treatment or examination rendered. Por Favor de enviar informacion de diagnosis y record de todo tratamiento o examen realizado.To: L&J Pediatrics, PA20338 NW 2nd Ave, Miami, FL 33169, TEL (305)-770-1937, FAX (305)-770-1468From:Please indicate from whom the Records will be coming from.Please send information, including diagnosis and records of any treatment or examination rendered. Por Favor de enviar informacion de diagnosis y record de todo tratamiento o examen realizado.From: L&J Pediatrics, PA20338 NW 2nd Ave, Miami, FL 33169, TEL (305)-770-1938, FAX (305)-770-1468To:Please indicate to whom we will be sending Records to.I hereby authorize you to release information including the diagnosis and records of any treatment or examination rendered to L&J Pediatrics, Pa. I am aware that the records released may contain information relating to physical testing, physical abuse, or drug and/or alcohol abuse. He aqui doy mi autorizacion para la transferencia de informacion medica, inclusive el diagnosis y record de todo tratameinto o examen relizado, a L&J Pediatrics, PA. Reconozco que es posible que la record transferida contiene informacion prueba fisica, abuso fisico, o abuso de drogas o de alcohol. *Yes, I authorizeName of Parent/Guardian *FirstLastPhoneSubmit