Complete this form for access to our online portal where you can receive electronic communication with our office, including receiving electronic health records.
Your relationship to the patient
I acknowledge that I understand this consent form. I authorize the release of medical information to myself at the email address above for the patient through Peggy Wongsa MD's secure internet portal. Please type "I AGREE" or "I DISAGREE" in the box below.
Type "I agree" to sign.
PLEASE NOTE: For all other types of records requested, please complete the Release of Medical Records Form on our website and fax the signed form to us or come to the office in person to complete the form.