Release of Medical Information - TO Dr. Wagner

Please note, it is not necessary to bring any prior medical records to your appointment. Dr Wagner will let you know, at your appointment, if she needs any other records.

To have a copy of your medical records from another provider released to Dr. Wagner, click below to print the release form... 

All information is required in order for your provider to release your records to our office.
Instructions - Provide the following information:
- Patient Name and Date of Birth
- The name, address, phone#  and/or fax# of the Provider who holds your records.
- Check the box of each record that you want released. Provide the date or date range for each item checked.
- Sign and date at the bottom. If you are not the patient, provide your relationship.

You have two options to submit your request:
 1. Return the completed form to us. We will submit the form to the Provider that holds your records.
 2. Give the completed form directly to the Provider that holds your records. We have provided our phone, fax and mailing address on the form so they can send your records to us.

   

Copyright © 2017 Laura Wagner, MD. All Rights Reserved.
14377 Woodlake Dr. #111 • Chesterfield, MO 63017
314-434-1111