Record Request

Use this form to authorize the release of your medical records from a previous physician or practice to Women’s Health of Greenwich.

I hereby authorize and request you to release my medical records in your possession concerning my illness and/or treatment.

Record Type

Please select what should be released *

Complete medical records including vaccination history Vaccination records only Specific treatment date(s) (please specify below) Most recent office note / labs / testing

Specification / note

Patient Information

First Name *

Last Name *

Date of Birth *

Address

City

State

Zip

Provider

Please email records to admin@womenshealthofgreenwich.com, upload them through the Medical Records page on our website, or fax to (833) 455-8163. Women’s Health of Greenwich, 75 Holly Hill Lane, Ste. 103, Greenwich, CT 06830. Phone (203) 822-6749.

Provider Name *

Previous Physician Information

Name *

Address

Phone / Fax

Additional contact information for the previous physician

Signature

Sign below using your mouse, trackpad, or finger.

Type your full name *

Today’s date *

Prefer to complete this on paper? Call us at (203) 822-6749 and we’ll be glad to help.

Record Request

Your Health.Our Priority.

Your Health.
Our Priority.