Records Type
*
prev
next
( X )
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
Date Picker Icon
I authorize Women’s Care of West Georgia/Veranet Healthcare to release my medical records
To
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
*
Today's Date
/
Month
/
Day
Year
Date Picker Icon
Comments
Submit
Should be Empty: