Medical Record Release Form

First Name *

Last Name *

Phone *

Email *

Pet(s) Name *

Where are records being transferred/released *

Veterinarian

Specialty/Referral Hospital

Boarding Facility

Grooming Facility

Self

How are records to be transferred/released *

Emailed

Faxed

Owner to pick up

Transfer email or fax number

Type of transfer *

I, the owner or authorized agent of the pet(s) listed above, request a copy or release of my pet’s medical records.

I understand that if I elected for this medical record to be permanently transferred, the medical record at Greenbrier-Springfield Animal Hospital will be marked as inactive. If I elected for this medical record to be a temporary transfer, the record will remain active at Greenbrier-Springfield Animal Hospital.

Please allow Greenbrier-Springfield Animal Hospital up to 5 business days to process, copy, and distribute the medical record.

I authorize the release of medical records *

I Agree

Date

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Medical Record Release Form

Option 1

Complete Online

Option 2

Complete on Arrival

Medical Record Release Form

New Patients Welcome