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Edward G. Miner Library
Phone: (585)275-2487
Fax: (585)273-1354
Miner_Information@urmc.rochester.edu

Ask a Medical Librarian:
Information Prescription

Date:
04/25/2014
Patient Name:
Date of Birth:
Medical Record Number (required)
(Patient type and related information are required)
Inpatient
Outpatient
Specify Unit:
I would like to review the information before it is sent to the patient/family member.
Describe Information Request:
Include background information about condition/any complicating factors that should be considered in the information retrieval (include patient's age; no acronyms please).
Healthcare Provider Name:
Telephone/Pager Number:
Provider's Division/Community Practice Name:
Attending Physician:

If you have trouble submitting this form call 275-2487 for assistance.