Montgomery County Fire and Rescue Service

Request for Incident Reports

Report Type Requested

Date and Approximate Time of Incident

Location of Incident

Patient's Full Name

Patient's Date of Birth

Property Owner's Name

Requestor's E-Mail Address

Requestor's Phone Number

Note: If you are requesting an EMS report, you may need to attach the following:

Signed Medical Release Authorization (not applicable if the requestor is the patient)
Power of Attorney (if patient is living but cannot request for themselves)
Letter of Administration or Executor Documentation (if patient is deceased)

Upload File(s)

Click Here to Upload

Additional Notes or Special Instructions:

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.