PACMC MEDICAL RECORDS REQUEST FORM

MEDICAL RECORDS REQUEST FORM

PAWS AND CLAWS MEDICAL CENTER - 3858 SW 137 AVENUE, MIAMI FL 33175 - WWW.PAWSNCLAWSMIAMI.COM - TELEPHONE 786-361-9344
PERSON REQUESTING MEDICAL RECORDS.
Pet Owner / Guardian Full Name

First NameLast Name
Phone Number
NUMBER MUST MATCH CURRENT RECORDSFormat: (000) 000-0000.
PET NAME
PET NAME
PET NAME
I, hereby authorize a full copy of the medical records including but not limited to all vaccines, prevention, laboratory testing, imaging, surgeries, hospitalizations of my pet (s) to be released promptly to:

RAMON DE ARMAS, DVM and/or PAWS AND CLAWS MEDICAL CENTER.

documents can be:

emailed to: outreach@pawsnclawsmiami.com

faxed to: 786-358-6065

snail mailed to: Paws and Claws Medical Center, 3858 SW 137 Avenue, Miami FL 33175.

Such records can be released whenever requested by this facility from now on.
INFORMATION OF VETERINARIAN / PET HOSPITAL RELEASING RECORDS
VETERINARIAN / PET HOSPITAL COMPLETE NAME*
Office Phone Number:*

Area CodePhone Number
Office Fax Number:

Area CodePhone Number
Office Email
example@example.com
Date

MonthDayYear
Date
Pet Owner Signature*
Should be Empty:

MEDICAL RECORDS REQUEST FORM