Doctors for Women
8001 Youree Drive, Suite 900
Shreveport, Louisiana 71115
Ph (318) 797-0101 Fax (318) 797-0010
Patient Name (full name)
______________________________________________
Birthday and
Age____________________________________________
Social Security
No.___________________________________________
Address____________________________________________________
__________________________________________________________
Phone
Home____________________________Work________________________
The undersigned hereby authorizes and
requests _____________________________
_______________________________________________________________
to provide Dr. Jacque T. LaBarre, Dr. Stephanie Sockrider and/or
Dr. Debra P. Cline of
Doctors for Women Clinic at the above
address with access to my
medical / hospital records for the purpose
of review and
examination and further request you
provide such copies thereof as may be requested.
The foregoing is subject to the following
time period:
Covering records for the period from
_____________________to ___________________
There are no limitations placed on
the above dates regarding history or illness,
or diagnostic and therapeutic
information, including treatment for alcohol and
drug abuse, or trreatment of any
sexually transmitted disease including HIV.
Signature________________________________________Date______________________