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Please forward records to:
Adolescent and Adult Women's Care/Dr. Montes
1052 13th Street SE
Hickory, NC 28602
(828) 485 - 2268 FAX


Patient ____________________________________________________________

Date of Birth ______________________________


Records requested from:

Name of Doctors Office/Hospital_____________________________________

Name of Doctor ______________________________________

Address________________________________________

City________________ State _____________ Zip Code_______________

Telephone Number _________________________________

Fax Number _______________________________________


Signature________________________________________________________


____________________________________________________________________________________________
To be completed by office personnel

RECORDS REQUESTED:

_____ All records

_____ Records from the last 5 yrs

_____ Last pap smear

_____ Last mammogram

_____ Records concerning surgery.

Name of surgery:_____________________________________

Approximate Date: ________________________