Kernersville Primary Care

KERNERSVILLE PRIMARY CARE

Family and Geriatric Medicine

William S. Kelly, MD, FAAFP, CAQ-Geriatrics Katie Scott Wingate, AGNP-C

Stephanie L Taylor, PA-C, CDE Nathaniel S. Kelly, MPH, RD, LDN

Dr. Kelly, Mrs. Taylor and Mrs. Wingate now have the capability to electronically share your medical information with your other medical providers when we make referrals or with hospitals. Not only are we able send electronically but we can receive important information. We would like your consent to use this exchange.

I authorize Kernersville Primary Care to use the electronic exchange:

______

Print Name

______

Signature Date

______

420 WEST MOUNTAIN STREET KERNERSVILLE NC 27284

Phone (336) 993-1618 www.kernersvilleprimarycare.com Fax (336) 993 5512