If you have visited any medical facility or other physician since your last visit please complete this form to ensure we have the information in your medical record

Choose your Medical Practice Name * Date of Birth Type of Medical Visit Name of Specialist Type of X-ray Name of Urgent Care , Hospital, Specialist or Xray Facility Date of Visit Did you request records be sent to Cary Adult Medicine Reason for Visit Treatment or Results of Visit Were you advised to follow-up with Cary Adult Medicine If you were to follow-up in what time frame were you to follow-up Have you scheduled a follow-up with Cary Adult Medicine Other Information