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2. First Name*

   Requestor's First Name.

3. Last Name*

   Requestor's Last Name

5. Email Address*
7. Requestor's Mailing Address*

   Please provide the Requestor's mailing address.

9. City*
10. State*
11. Zip Code*
13. Which report are you requesting?*

    Please check the box next to the report(s) you are requesting. *EMS Report request requires you to fill out the form Patient Request for Access to Protected Health Information. Click the link to the right of this field.

    1. EMS Report*
    2. Fire Report
    3. Fire Investigation Report
14. Patient Request for PHI
    Patient Request for Access to Protected Health Information
15. Why are you requesting this report?*

    Please give a brief description of why you are requesting this report.

17. Phone Number*

     Please provide the Requestor's phone number.

18. Is the Requestor the Involved Person(s)/Property Owner*

    1. Yes
    2. No

    There is no fee for Involved Person(s)/Property Owners. There is a $15.00 fee for Uninvolved Person(s)/Non-Property Owners.

20. Incident Address*

    Please provide the address where the incident took place.

22. City*
23. State*
24. Zip Code*
26. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident

    Please provide the date of the incident and the time to the best of your ability.

27. Uninvolved person(s)/Non-Property Owners

    There is a $15.00 fee for Uninvolved Person(s)/Non-Property Owners. Payment by cash or check can be mailed or brought in person to:

     Laconia Fire Department, c/o Fire Prevention

    848 North Main Street

    Laconia, NH 03246

    Payment by credit card (2.99% fee) will be IN PERSON ONLY at the above address.

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field