Carolinas HealthCare System
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Patients Forms

Please print, complete and bring the following forms to your appointment at Charlotte OB/GYN:

New Patient Forms

Established Patient Forms

If you need to update your information, please download, print and complete the necessary forms below and bring to your next appointment. The document(s) will replace what we currently have on file.

Physical Review

Release of Medical Records

All requests for medical records must be submitted in writing. Please include the following information:

  1. Patient's name
  2. Patient's date of birth
  3. Patient's social security number
  4. Name and complete address of where information is to be sent
  5. Dates of service and type of information to be sent
  6. Patient or guardian signature and date
  7. Name and telephone number where you can be reached
  8. Reason for request

Authorization for Release of Health Information (PDF)

Please mail or fax your written request to your practice. Find your Charlotte OB/YGN location

Requests will be processed in seven to 10 business days; a processing fee may be charged.

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