Request For Release Of Medical Information | Travers Lasik
CALL OR TEXT: (919) 510-6830 info@traverslasik.com

REQUEST FOR RELEASE OF MEDICAL INFORMATION



  • To release ALL MEDICAL RECORDS pertaining my health / eye examinations including but not limited to:

    • REQUIRED: Autorefractor tape or data
    • Minimum 2-3 full exams (if available) more may be requested if needed
    • Keratometry
    • Refraction with visual acuity
    • Ocular / systemic health
  • Please submit to:
    Travers Lasik Vision Center
    2501 Atrium Drive, Suite 200
    Raleigh, NC 27607
    Phone# (919)510-6830
    Fax# (919)510-6835



  • Staff Signature