Chico AH - Medical Record Request

1

Please allow 5 business days to receive medical records.

2

Today's Date* This field is required.

Date

3

Owner Information* This field is required.

Owner Last Name

Owner First Name

Owner Email

4

Pet's Details

Pet's Name(s)

5

Sending Records To:

Facility Name

Phone

Email: If no facility email is provided records will be sent to the owner's email

6

Please provide the reason for this request* This field is required.

8

Please provide details for "Other"

10

If you selected "Other," please explain

11

Was there a specific incident that influenced your decision to leave our practice?* This field is required.

Yes

No

Prefer not to say

12

If yes, and you're comfortable sharing, please tell us more

14

What could we have done differently to keep you as a client?

15

Any final thoughts or suggestions for us?

16

Signature* This field is required.It may take up to 5 business days to send medical records.

Clear