Information Request Form

Record Request

This form is strictly for use by Veterinary Hospitals & Insurers only.

If you are a medical facility, groomer, or boarding facility & only need a verbal vaccine history/verification, please call our office at 561-625-6970.

While we do our best to complete all requests as soon as possible, non-emergency record requests for medical providers can take up to 14 business days to process. Requests for insurers can take up to 30 days to process.

Thank you for your patience & understanding as we prioritize patient care during these challenging times. If you have any questions, please contact Management@IbisAnimalHospital.com

Client & Patient Info

Client Name

First NameLast Name

Phone Number

Area CodePhone Number

Purpose of the visit:

Pet's Name(s):

Requesting Practice or Insurer Info

Hospital or Insurer Name:

E-mail:

Fax Number:

Area CodePhone Number

Phone Number:

Area CodePhone Number

Staff Member Requesting:

Continued

Please select the appropriate option.

Records Being Requested:

Please select all that apply.

Is there anything else we should know?

If the patient is currently scheduled for an appointment at your practice, please note the date.

Date

Records Request

We no longer have records for this patient.