Patient Forms


Your Personal Health Record

A personal health record (PHR) is a collection of important information that you maintain about your health or the health of someone you’re caring for, such as a parent or a child that you actively maintain and update. The more complete and accurate your health information is, the better tool you have to help you play an active role in your own quality healthcare.

Here at Gaylord, we understand the importance of maintaining a PHR, and we value the concept of providing our patients with a copy of their health information so it may be used to support ongoing care.

For our inpatients, we will send a copy of pertinent portions of your medical record to your requested mailing address after you are discharged, free of charge. This information will help build your own health information profile. For Outpatient and Sleep Medicine patients, we will offer you information on how to obtain a copy of your information and why it is important to build your own record of your care form every provider you are in contact with (see link at right).

For more information on why it is important to maintain your own health information, visit: Contact Gaylord’s Privacy Officer for any questions you may have about your health information by writing to: or call (203) 741-3303.

Request for medical records

Patients treated at Gaylord Hospital can request a copy of their medical records by submitting a signed authorization form.

Please choose to print the appropriate form, then complete it and return to Gaylord Hospital:


Gaylord Hospital Gaylord Wellness Center Gaylord Sleep Medicine / Guilford
Gaylord Hospital

Gaylord Farm Road

Wallingford, CT 06492

(203) 284-2800

Gaylord Physical Therapy, Orthopedics
and Sports Medicine

8 Devine Street

North Haven, CT 06473

203-230-9226 / 203-284-2818 Sleep Medicine

Gaylord Specialty Healthcare