RELEASE FORM

Date of Request____________________________

To: Charlotte Primary Care

1918 RANDOLPH ROAD, SUITE 440

Charlotte, NC 28207


I hereby request that an entire copy of my medical records be sent to Dr. Kim Tam, Dr.Sheena Kapadia, and Dr. Stephanie Glenn at the above address, including but not limited to all office notes, radiology reports, laboratory analysis and EKGs. Thank you for you prompt attention.

Sincerely,



____________________________________
Patient's Signature


Patient's Full Name_________________________________

(Other Names Used, If Any_________________________________)

Patient's Social Security Number___________________________

Patient's Date of Birth________/________/________