{"id":400,"date":"2026-04-23T13:40:30","date_gmt":"2026-04-23T17:40:30","guid":{"rendered":"https:\/\/11-design.com\/mammo\/?page_id=400"},"modified":"2026-04-23T13:49:40","modified_gmt":"2026-04-23T17:49:40","slug":"forms","status":"publish","type":"page","link":"https:\/\/11-design.com\/mammo\/forms\/","title":{"rendered":"Medical Records Request Form"},"content":{"rendered":"[vc_row type=”in_container” full_screen_row_position=”middle” column_margin=”default” column_direction=”default” column_direction_tablet=”default” column_direction_phone=”default” scene_position=”center” bottom_padding=”45″ text_color=”dark” text_align=”center” row_border_radius=”none” row_border_radius_applies=”bg” row_position_desktop=”default” row_position_tablet=”inherit” row_position_phone=”inherit” overflow=”visible” overlay_strength=”0.3″ gradient_direction=”left_to_right” shape_divider_position=”bottom” bg_image_animation=”none” gradient_type=”default” shape_type=””][vc_column column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”all” flex_gap_desktop=”10px” column_element_direction_desktop=”default” column_element_spacing=”default” desktop_text_alignment=”default” tablet_text_alignment=”default” phone_text_alignment=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_backdrop_filter=”none” column_shadow=”none” column_border_radius=”none” column_link_target=”_self” column_position=”default” gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1\/1″ tablet_width_inherit=”default” animation_type=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid”][vc_column_text css=”” text_direction=”default”]\n

Medical Records Request Form<\/span><\/h1>\n

Please allow up to 48 hours after your exam has been completed before requesting records.<\/p>\n

You may access your patient portal at any time:<\/strong>[\/vc_column_text][nectar_cta btn_style=”text-reveal-wave” heading_tag=”span” link_type=”new_tab” button_color=”accent-color” text_color=”#ffffff” button_border_thickness=”0px” alignment=”center” alignment_tablet=”default” alignment_phone=”default” constrain_group_3=”yes” constrain_group_4=”yes” display=”inline” display_tablet=”inherit” display_phone=”inherit” icon_family=”none” link_text=”Patient Portal” padding_top=”0.6em” padding_bottom=”0.6em” padding_left=”1.4em” padding_right=”1.4em” margin_right=”1em” url=”https:\/\/mammolink.patientpal.com\/login”][\/vc_column][\/vc_row][vc_row type=”in_container” full_screen_row_position=”middle” column_margin=”default” column_direction=”default” column_direction_tablet=”default” column_direction_phone=”default” scene_position=”center” bottom_padding=”32″ left_padding_desktop=”7%” constrain_group_2=”yes” right_padding_desktop=”7%” left_padding_tablet=”5%” constrain_group_4=”yes” right_padding_tablet=”5%” text_color=”dark” text_align=”left” row_border_radius=”none” row_border_radius_applies=”bg” row_position_desktop=”default” row_position_tablet=”inherit” row_position_phone=”inherit” overflow=”visible” overlay_strength=”0.3″ gradient_direction=”left_to_right” shape_divider_position=”bottom” bg_image_animation=”none” gradient_type=”default” shape_type=””][vc_column column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”all” flex_gap_desktop=”10px” column_element_direction_desktop=”default” column_element_spacing=”default” desktop_text_alignment=”default” tablet_text_alignment=”default” phone_text_alignment=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_backdrop_filter=”none” column_shadow=”none” column_border_radius=”none” column_link_target=”_self” column_position=”default” gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1\/1″ tablet_width_inherit=”default” animation_type=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid”][vc_row_inner column_margin=”default” column_direction=”default” column_direction_tablet=”default” column_direction_phone=”default” text_align=”left” row_position=”default” row_position_tablet=”inherit” row_position_phone=”inherit” overflow=”visible” pointer_events=”all”][vc_column_inner column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”all” flex_gap_desktop=”10px” column_element_direction_desktop=”default” column_element_spacing=”default” desktop_text_alignment=”default” tablet_text_alignment=”default” phone_text_alignment=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_backdrop_filter=”none” column_shadow=”none” column_border_radius=”none” column_link_target=”_self” overflow=”visible” gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1\/1″ tablet_width_inherit=”default” animation_type=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid”]\n

\n

<\/p>

    <\/ul><\/div>\n
    \n
    \n<\/fieldset>\n
    \n\t
    \n\t\t

    Full Name*<\/span>
    \nPhone*<\/span>\n\t\t<\/p>\n\t<\/div>\n\t

    \n\t\t

    Birthday*<\/span>
    \nEmail Address*<\/span>\n\t\t<\/p>\n\t<\/div>\n\t

    \n\t\t

    Home Address*<\/span>
    \nIf you need a copy of your report sent to your physician, please enter their full name and correct fax number*<\/span>
    \nIf additional imaging or follow up has been advised by your physician, please let us know where you want your images sent:
    \n

    \n\t\t\t

    If you answered FACILITY above, please enter the name and address of the facility you would like them to be sent<\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t

    \n\t\t<\/p>\n\t<\/div>\n<\/div>

    <\/div>\n<\/form>\n<\/div>\n[\/vc_column_inner][\/vc_row_inner][\/vc_column][\/vc_row]\n","protected":false},"excerpt":{"rendered":"

    [vc_row type=”in_container” full_screen_row_position=”middle” column_margin=”default” column_direction=”default” column_direction_tablet=”default” column_direction_phone=”default” scene_position=”center” bottom_padding=”45″ text_color=”dark” text_align=”center” row_border_radius=”none” row_border_radius_applies=”bg” row_position_desktop=”default” row_position_tablet=”inherit” row_position_phone=”inherit” overflow=”visible” overlay_strength=”0.3″ gradient_direction=”left_to_right” shape_divider_position=”bottom” bg_image_animation=”none” gradient_type=”default” shape_type=””][vc_column column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”all” flex_gap_desktop=”10px” column_element_direction_desktop=”default” column_element_spacing=”default”…<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"content-type":"","footnotes":""},"class_list":["post-400","page","type-page","status-publish"],"_links":{"self":[{"href":"https:\/\/11-design.com\/mammo\/wp-json\/wp\/v2\/pages\/400","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/11-design.com\/mammo\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/11-design.com\/mammo\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/11-design.com\/mammo\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/11-design.com\/mammo\/wp-json\/wp\/v2\/comments?post=400"}],"version-history":[{"count":11,"href":"https:\/\/11-design.com\/mammo\/wp-json\/wp\/v2\/pages\/400\/revisions"}],"predecessor-version":[{"id":413,"href":"https:\/\/11-design.com\/mammo\/wp-json\/wp\/v2\/pages\/400\/revisions\/413"}],"wp:attachment":[{"href":"https:\/\/11-design.com\/mammo\/wp-json\/wp\/v2\/media?parent=400"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}