Required fields are marked with an *

Patient and Contact Data

Patient First Name:

Patient Last Name:

Date of Birth:

Contact Name:

Phone Number:

MRN (if known):

Appointment Date at Gillette:

Appointment Type at Gillette:

Completed By (if done by Gillette staff):

Referring Facility Name:

Has the patient been seen for any of the following?

Check all that apply and then answer follow-up questions. Changing any options will clear all follow-up answers.

Other Imaging and Specialty Care Records?

If you have been seen at more clinics that have more records (not listed above), please use the button "Add More Clinic Information" to add up to 5 clinics.

Select Files To Upload

Don’t have the ability to upload records in this moment? You can additionally upload in the following ways:

Attach records to a portal message – https://www.gillettechildrens.org/your-visit/mygillette-patient-portal
Email: PA-Records@gillettechildrens.com
Fax: 651-325-2137

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Additional Resources

Additional Resources

Additional Resources

Gillette Children’s Records Collection Form

Required fields are marked with an *

Patient and Contact Data

Referring Facility Name:

Has the patient been seen for any of the following?

Check all that apply and then answer follow-up questions. Changing any options will clear all follow-up answers.

Record Upload Questions

Other Imaging and Specialty Care Records?

Select Files To Upload