AUTHORIZATION OF CARE FORM

AUTHORIZATION OF CARE FORM
Dear Valued Patients,

We are excited to announce an exciting new chapter for Central Carolina OB/GYN. Effective September 17, 2026, our practice will become an independent, physician-owned practice. This decision reflects our commitment to providing the highest quality care while giving us the freedom to make decisions based solely on what is best for our patients and our community. For 24 years, Dr. Dillard, and for 23 years, Dr. Roberts, have been privileged to care for women and families throughout our community. They remain deeply committed to providing the compassionate, personalized care you have come to expect and are excited about the future of our practice.

Our primary focus remains on you—our patients—and ensuring your care continues without interruption.
Please check one of the boxes below:
The North Carolina Medical Board makes it clear that patients’ welfare, autonomy and continuity of care is the foremost consideration. North Carolina law gives every patient the right to choose their healthcare provider.

Our mission has always been to provide exceptional medical care with compassion, respect, dedication and inclusivity. That commitment is not changing!

Thank you for the trust you have placed in us. We sincerely appreciate the opportunity to continue being part of your healthcare journey.

With gratitude,

Dr. Angela Roberts

Dr. Naima Dillard
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Signature
Date Signed

MonthDayYear
Date
Parent or Legally Authorized Representative (if applicable)

In case the subject is beyond the legal age of consent:
Name of Parent or Guardian

First NameLast Name
Relationship to Subject
Signature of Parent / Guardian
Date Signed

MonthDayYear
Date
Should be Empty: