Form Fee Policy

Please complete the form below to acknowledge you will be charged for the fees associated with requesting forms or letters to be completed by Bridgepoint Clinic.

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Email(Required)

Best Contact #(Required)

Today's Date(Required)

Fees:

Patient Record Request	$30.00
DFCS Record Request	$30.00
Attorney Record Request	$30.00
Insurance/Disability Request	$30.00
Doctor’s Office Request	$0.00

How To Send:

Fax

Mail

Street Address Address Line 2 City State ZIP Code

Pick-Up

We accept payment via credit card, debit card, or cash. We do not accept personal checks. Do not send cash in the mail.

Every effort will be made to complete your forms as soon as possible. However, please allow 7-10 business days for completion.

Please sign below to acknowledge that you will be charged for any fees associated with requesting forms and letters.

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