Transfer Medical Records Request

Record Transfer Request

Routine medical records are automatically sent to your family veterinarian on file. This form is only needed if you are seeking care at another specialty hospital or if have changed to a new family veterinarian.
Your Pet's Name *
Primary Owner or Authorized Agent on Record *

First Name Last Name
Best Contact Number *
Please enter the best number to reach you
May we send text messages? *
Your Email Address: *
example@example.com
Clinic Name and Location *
Please be specific. Several facilities have similar names
Clinic Email or Contact Information (if known)
If you have been provided a specific email or fax number for record submission, please enter above. Otherwise, we have general contact information for local Bay Area hospitals
Specific Veterinarian or Specialty Service (if known)
I certify that I am the legal owner or authorized agent for the above referenced pet. I hearby give PETS Referral Center permission to transfer all medical records and diagnostic images on file to the above facility
Signature *

Clear
Submission Date

Month Day Year
Date
Submission Time

: Hour Minutes AM/PM Option
Should be Empty:

Record Transfer Request