Please have my medical records transferred to Dr. Andre Gilbert's office at Cascades Urology Center.
Date: ______________________ Patient's Name (Print): ___________________________________________ Patient's Signature: _____________________________________________ Date of Birth: ________________________ Phone #: ___________________________
Patient's Name (Print): ___________________________________________
Patient's Signature: _____________________________________________
Date of Birth: ________________________
Phone #: ___________________________
Cascades Urology Center 1651 North Lake Court Findlay, OH 45840 Phone: 419-423-8090 Fax: 419-423-8902
