Records Request

If you would like to request a copy of your medical records, please fill out the form below. Accurate information is necessary to verify your identity and ensure the confidentiality of your medical information. Once your request is submitted, we will process it and aim to send your records to you within 2-3 weeks after our office closes.

Important Information:

Last Day for In-Person Record Pickup: November 15, 2024
Office Closure Date: November 26, 2024
Records Availability: Up to 10 years following your last appointment
Request Process After Office Closure: Complete the form below

Thank you for your cooperation during this transition.

Name(Required)

First Last

Email(Required)

Date of Birth(Required)

How would like to receive your records?(Required)

Pick Up in Office

Physical Mail

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

1505 Eastland Dr. Suite 350
Bloomington, IL 61701
Phone: (309) 663-1222
Toll Free: (888) 841-4108

Dr. Jeffrey Poulter specializes in procedures such as abdominoplasty, liposuction, body contouring after weight loss, BOTOX® Cosmetic injections, and breast augmentation for Illinois residents from areas including Bloomington, Normal, Decatur, Peoria, and Champaign, as well as patients from throughout the Midwest and beyond.

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Records Request