Request for EMS or Fire Report

Address *

Primary Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
E-mail *
Part II: EMS Report Requests - Patient Information
Patient's Name *

First Name Last Name
Patient's Date of Birth *

Month Day Year
Date of Incident *

Month Day Year
Address of Incident *
Relationship to Requester *

Self Spouse Child Other
If other, please specify *
Note: EMS Reports emailed to the requester are required to be encrypted with a password for privacy protection. You will be required to enter this password in order to open the emailed document.
Note: Written documentation supporting legal right to such protected class information is required in cases where the requester is neither the patient nor the legal guardian for the patient. Such documentation must be provided at the time the request is submitted.
Part III: Fire Report Requests
Date of Fire *

Month Day Year
Address of Fire *
Should be Empty:

Part 1: Requester Information