Click on Calendar, type the year "YYYY" and pick the month & date.
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,
23535 Kingsland Boulevard, Katy, Texas 77494
Phone: 855-346-8610
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 :


   


This document or documents accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of the information is prohibited from disclosing this information to any other party unless required to do so by law or regulation and is required to destroy the information after stated need has been fulfilled. If you are not the intended recipient, you are hereby notified that any disclosure, copying distribution, or action taken in reliance on the contents of these documents strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or destruction of these documents.