Medical Record Request Form

Pursuant to applicable state laws we only maintain patient records for 3 years. No records will be sent for an inactive patient that we have not seen in over 3 years. We are also now required to have written confirmation of all medical record requests. Please fill out the following form. It can take up to 5 business days for medical records to be sent. Our priority is to the patients in the hospital at this time. If you are making an appointment for a specialist referral please take time frames into consideration and give us ample notice to get records sent.

Client Name*

First Last

Full Patient Name*

First

Email*

Reason Your Requesting Records*

Insurance Request
Boarding/Grooming
Specialist Referral
Switching Vets
Moved Out of Area
Records for Myself for Emergency Purposes

Reason for Switching Vets:

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