Please complete this form to request medical records to be released to The Fertility Center of Las Vegas/Ovagen Fertility/Granite Surgery.
Insert your Doctor's name here.
8851 W, Sahara Ave. Suite 100 Las Vegas NV 89117
FAX: (702) 254 1213
- Records should be from within the past 12 months from an OBGYN, Primary Care, Perinatologist, or other Fertility Specialist.
Please use a mouse on your desktop/laptop or a stylus / your finger to sign on a tablet.