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Medical Records Request
Submitting a records request is easy! Just fill out our online form and one of our staff members will fulfill the request. Please allow 24-48 hours following your online request.
Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Are you a Client or Veterinary Hospital?
*
Client
Veterinary Hospital
Hospital/Person Inquiring:
*
Name
Pet(s) Name:
*
Name
Client's Name
*
First Name
Last Name
Secondary/Alternative Client Name
First Name
Last Name
Client's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary/Alternative Client Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email we should send the records to (Preferred Method):
*
example@example.com
Additional email to receive records:
example@example.com
Fax number we should send the records to (Only if email is unavailable):
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Visit (If Known):
-
Month
-
Day
Year
Date
Notes (Please let us know if specific information is needed):
Submit
Should be Empty: