Medical Records Request Form

Save time during your upcoming appointment! Before your visit, fill out your form online at any time from any device.

Medical Records Request form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Select Location *

Client's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Pet's Name *

I request that copies or summaries, as required by state law, of the medical records pertaining to my animal(s) named below be released to the following veterinary practice. As owner of patient(s) listed above, I will be responsible to deliver records to practice below.

Pet's Name

Name of Practice

Layout

Signature of Owner or Authorized Agent *

Today's Date *

Signature of Veterinarian who approves this request

Today's Date

Medical Records Request Form

Medical Records Request form

Have A Question?

Peoria Location

Dunlap Location

Chillicothe Location