Thermography Records Request

Please complete this form to have your records sent to any provider of your choosing. You must complete this form for EACH report you would like us to send. Once the request has been completed you will receive an email verification that we have completed your request. 

Due to the file type for our imaging and interpretation, all reports must be emailed. They cannot be submitted to any facility radiology (PACs) systems, or transmitted via fax. A valid facility email address or phone number must be provided in order for your request to be completed.

Records Request

By completing the form below you authorize Seiana Wellness, dba InfraMed Thermography, to release your encrypted thermography report to the contact you provide. You hereby release Seiana Wellness, dba InfraMed Thermography, and its affiliates of all liabilities regarding these records. I further understand that this request is a ONE TIME use form and completing this form will allow your records to be sent to ONLY the party you have identified, one time. You will receive a notification when this request has been completed. 

Thanks for submitting!