Obstetrics & Gynecology
of North Texas
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Physicians
Services
Forms
FAQ
Contact
Medical Release
Important!
No sensitive information is stored on the website. Everything is securely sent directly to the office for processing.
Patient's Name
Please provide a name
Other Name(s) Used
Date of Birth
Please select a date
Authorize our office to request records from another office
Name of Doctor, Clinic, or Hospital
Address
City, State, Zip
Phone
Fax
Release my records to physician
-- Select a physician --
Robert B. Wai, M.D.
Julia C. Flowers, M.D.
Carrie P. Morris, M.D.
Sofia A. Lieser, M.D.
Authorize our office to send records to another office
Name of person, facility, or agency to which the information should be released
Address
City, State, Zip
Phone
Fax
Email
**HEALTH INFORMATION TO BE RELEASED**
I specifically authorize release of the following information:
Entire Medical Record
Description
From
To
History/Physical Exam
Description
From
To
Progress Notes
Description
From
To
Lab Report
Description
From
To
X-ray/Ultrasound Reports
Description
From
To
Other
Description
From
To
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