CLient Registration Form

Records Request
If you have elected another practice to provide continuation of care for your pet, or would like us to send vaccination records for grooming or boarding, you can complete the following form to facilitate that request. Records will be e-mailed to the practice or business of your choosing. We will do our best to accommodate any request for records within 24-48 hours that are made during our business hours. Weekend requests will be processed as if they were received on Monday.

Tennessee Law requires that all requests for medical records be provided in writing. This form will be considered your written approval to share your pet's medical records as you have directed.

All information on the form must match what we have on record for your account. If the information does not match we may not be able to accomodate the request. These requirements are in place to ensure those requesting records are who they claim, and requests are received only by those authorized on the account. This is to ensure we are in compliance with the Tennessee Veterianry Practice Act. Your co-operation is appreciated.
Primary Owner Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Format: (000) 000-0000.
Cell Number if not Primary Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail*
example@example.com
Primary Account Holder Birth Date*

MonthDayYear
Date
Driver's License Number *
Driver's License State*
Secondary User Name

First NameLast Name
Secondary User Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Account userSecondary Account user

Second Pet for Records Request

Tell us which other pet's records you like us to forward.
Pet's Name*
CanineFelineAvianOther
MaleNeutered MaleFemaleSpayed FemaleUnknown

Where would you like us to send them.

Tell us where you like us to forward a copy of your pet's medical records too.
Please send only vaccination and wellness records.Please send the complete record, or as requested by the recipient.
Please send me a copy to my email on file.Please send to a Boarding or Grooming Facility.Please send them to a Veterinary Practice.Other
Name of Practice, Business, or Person we are sending a copy of medical records to.*
Phone number of recipient.*
Please enter a valid phone number in case we need to contact them.Format: (000) 000-0000.
E-mail for recipient.*
example@example.com
You are approving that we send your pet's medical records to the above recipients.

Your approval will mean we are sending either vaccine records or full records to your designated recipients. Please allow a minimum of 24-48 for the request to be completed. Each veterinary hospital has their own policies in regards to how they process medical records requests.
Yes, I give consent for you to send records to the recipients listed above.

Electronic Signature
Type your Full Name as you Electronic Signature*
Full Name of Primary Account User
Date*

MonthDayYear
Date
Should be Empty:

Records Request

Pet Profile

Second Pet for Records Request

Second Pet for Records Request

Where would you like us to send them.

You are approving that we send your pet's medical records to the above recipients.

Electronic Signature