Medical Record Transfer Request Consent to Transfer Medical Records to and from Range Road Veterinary Clinic.Please enable JavaScript in your browser to complete this form.Name of pet owner: *FirstLastPrimary Phone Number (to verify identity): *Address on client file (to verify identity): *Please make sure to include house/unit number, street name, city, province and postal code. above client Name Name of Pet(s) being transferred: *SENDING CLINIC. Name of the Veterinary Clinic that the requested files are being sent FROM: *RECIEVING CLINIC. Name of the Veterinary Clinic that the requested files are being sent TO: *By signing below I authorize copies or summaries of the medical records pertaining to my animal(s) be released from the above listed sending clinic to the receiving clinic. *Date of Request (mm/dd/yyyy): *Submit
