Medical Records Request

Records Type *

Records printed for patient $ 35.00

Records sent to another medical office Free

Patient Name *

First Name Last Name

Email Address *

Phone Number *

Date of Birth *

/ Month / Day Year

I authorize Women’s Care of West Georgia/Veranet Healthcare to release my medical records

To *

Address *

Phone *

Fax

Please check any documentation that you request for us to send or receive *

All Records Path & Lab Reports Pap Smears Prenatal Operative Reports X-rays H&P’s Discharge Reports Biopsy Repo

Patient Signature *

Clear

Today's Date

/ Month / Day Year

Comments