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855 346 8610
23535 Kingsland Boulevard, Katy, Texas 77494 | Directions
Obgyn Katy TX - Personal & Quality Care for Women in All Phases of Life
Personal & Quality
Care for Women in
All Phases of Life
T L Jenkins MD

Medical Records Request

Please note that it is important to fill in all the fields before submitting. Thank you.
* I hereby authorize (Previous Doctor) :
Address:
City :
State :
Zip :
Phone Nubmer: ()--
Fax Nubmer: ()--

* To furnish a copy of medical records, this may include information concerning the results and/or drug abuse, of the patient listed below upon making request. I hereby release you, our physicians and employees from liability for following this authorized release form.
TO: Jenkins Ob/Gyn and Reproductive Medicine,
23920 Katy Freeway, Suite 215 Katy, Texas 77494,
Phone: 281-347-2600
Fax: 281-347-2603
****THIS AUTHORIZATION IS VALID FOR 120 DAYS FROM THE DATE OF SIGNATURE ANY CHANGE IN AUTHORIZATION MUST BE IN WRITING****

Specific information requested: Date of Service:
Pap Smear Office Notes
Labs Mammography
Operation Prenatal Record
All
*Patient Last Name :
Middle Name :
*First Name :
Date of Birth:
Social Security #:
Phone#: ()--
Home Address:
City :
State :
Zip :
Apt. # :


*Signature:
Date :