Medical Record Transfer Request

pertaining sent the

Name of pet owner: *

First

Last

Primary 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.

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): *

Medical Record Transfer Request

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