A Message from Dr. Shahira Boulos

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Date of Practice Closure: March 16, 2017

“I have enjoyed being your Family Physician and it has been a privilege to assist with your health care needs.

I strongly recommend that you obtain a copy of your personal medical history from RSRS. This information is important for your continued care and may not be available to you or your next healthcare provider otherwise.”

DR. SHAHIRA BOULOS M.D.

To obtain a copy of YOUR MEDICAL RECORD please complete the following form. A member of our Patient Services team will then be in contact with you. (If your request is of an urgent nature, please call us at 1-888-563-3732 Ext. 1)

Medical Record Request Form

I am requesting a medical record for (choose only one):
- Myself only
- Myself and other family member(s)
- Other family member(s) only
(Someone outside your family? Click here.)
I am requesting my medical record(s) from the practice of (Doctor's Name):*
First Last
My name:*
First Last
My phone number:*
My cellphone number:
Email*
Enter Email Confirm Email
The best time to reach me is (choose only one)
- Anytime
- Morning
- Afternoon
- Evening
- 9 am - 5pm
Patient Name:*
First Last
Date of Birth is*
MM
DD
YYYY
I last saw this doctor (choose only one):*
- Within the last 12 months
- 2-3 years ago
- 4+ years ago
- Can't Remember
Request additional records:
Please list any additional family members for whom you are requesting medical records. Include Date of Birth for each as well as the date when each last saw the doctor.
Click on + button to add more family members:
First name Last name Date of Birth Date Last Saw Doctor
Emergency Request (e.g., imminent surgery, serious/critical illness)
For emergency matters only. If you select this option, immediately call 1-888-563-3732, Ext. 205 and leave a message explaining your extraordinary circumstances and timeline.
- Emergency request
Please notify me of information that may impact my medical record and/or future healthcare tracking.
- Yes. Please keep me notified.
- No. I do not wish to be further notified

Note:

A Release of Information Form must be completed and signed prior to the release of any medical information. If you do not have one, RSRS will supply you with one.
You are entitled to a COPY of your patient record. An original paper record is the property of the physician and must be retained in storage for a period of time, after which it is shredded.
Each patient of legal age or older must sign for the release of his/her own record.
There is a fee for the transfer of medical information. The fee is set in accordance with guidelines. The fee is not prohibitive and records are not withheld once properly authorized for release.

If you have any problems using this form or if you have questions, please contact RSRS by telephone at 1‑888‑563‑3732, Ext 1 or email info@rsrs.com.

Date of Practice Closure: March 16, 2017

Medical Record Request Form

Request additional records: