Medical Record Request Form printable pdf download

Medical Record Request Form

17945 State Road 54

Lutz, FL 33558

PH: 813-926-1126

FAX: 813-926-5264

Medical Record Request Form

Date: ________________

Parents Name(s): __________________________________________________________________________

Patient Name(s): ___________________________________________________________________________

Address: _________________________________________________________________________________

Phone: (

) _____________

Email: _____________________________________________________

_____________________________________________

Reason for Request:

Relocation:

New Address

__________________________________________________________________________________________

Veterinary Facility:

Specialist: ____________________________________________________________

Name

________________________________________________________________________

Reason for Visit

Family Veterinary Hospital: ______________________________________________

Name

__________________________________________________________________________

Reason for Visit

Other:

________________________________________________________________________________________________

Explanation

Requesting Full Medical Records: (Please allow 48 hours for processing)

Options:

Pick – up

Mail to current address above

Mail to my new address listed

Pet Parents Signature: ______________________________________________________________________

Printed Name: ____________________________________ Date: ___________________________________

In-Office Use (Initial)

Driver’s License Number ____________________________________ Copy DL of file: _______ Approved_________

Called for Pick-up_________ Parent picked up___________ Mailed_____________ Marked in Avimark: ____________

Medical Record Request Form