Al Jalila Children’s Request Medical Report

Please attach Emirates ID or Passport:*

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The maximum file size allowed is 5MB (.jpg, .jpeg, .png, .pdf)

Email:*

Contact No:*

The release of medical information shall be done via:*

Pickup(Hardcopy) Email

*Reports will only be released in English. Please ensure completion of all fields. Submission of an incomplete form will result in delay of issuance of medical records. Reports will only be emailed to the email ID provided at the time of admission. A hard copy can be collected by presenting valid identification documents.

Type of information to be disclosed (Please check one that applies)*

Autism Spectrum Disorder Report

Laboratory/pathology Reports

Radiology reports (X-Ray, Ultrasound, CT, MRI Reports)

Discharge Summary (maximum 3 working days from the date of discharge)

Rehab Report - AED 270 (VAT excluded)

Medical Report - AED 270 (VAT excluded)

Mental Health Medical Report - AED 270 (VAT excluded)

Do you require attestation?*

Yes No

Terms and conditions *

I have read and accept all following terms and conditions.

Medical reports for all cases (except Mental Health) will be sent within 3 working days upon successful payment.
Diagnostic reports (laboratory/pathology/radiology) will be sent within 3 working days based on availability of test results.
I hereby authorize Al Jalila Children’s to release the requested protected health information to the registered email ID.
I understand that the specified information is confidential and may include but not limited to health history, diagnosis, treatment, prognosis, mental health illness or communicable diseases.
Al Jalila Children’s is not responsible for unauthorized access of this protected health information while in transmission to the registered email address or re-disclosure of it by the recipient

Patient Details

Al Jalila Children's Specialty Hospital

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