Request For Transfer Of Medical Records - Niagara Frontier Veterinary Society printable pdf download

Request For Transfer Of Medical Records - Niagara Frontier Veterinary Society

Niagara Frontier Veterinary Society

REQUEST FOR TRANSFER OF MEDICAL RECORDS

By law, original medical records must be retained for five years after the last entry.

However, a copy or summary of the information contained in these records can be

forwarded.

The confidentiality of your pet’s health information is very important.

Accordingly, we ask you sign where indicated to authorize the release of your pet’s

medical information.

CLIENT NAME:

__________________________________________

ADDRESS:

______________________________________________

PHONE:

______________________________________________

PET’S NAME: ___________________ DATE OF BIRTH: ___________

Circle one:

CAT

DOG

Other

(Please complete a separate form for each pet)

I authorize the release of a copy of the medical records for the above animal.

From:

________________________________________________

To:

________________________________________________

Phone: _______________

Fax: ___________________

Pet Owner Signature: __________________________________________

Date:

______________

[ ] Check here if this is a permanent transfer and you no longer wish to receive

mailings from your previous hospital.

Request For Transfer Of Medical Records - Niagara Frontier Veterinary Society