Request For Transfer Of Medical Records

By of Law, original medical records must be retained for five years after the last entry.?However, a copy or summary of the information contained in these records can be forwarded.?The confidentiality of your pet’s health information is very important.?Accordingly, we ask you sign where indicated to authorize the release of your pet’s medical information.

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Thank you for your response. ✨

Client Name

Address

City

State

Zip Code

Phone Number

Pet Name

DOB

Check One:

Dog Cat Other

(Please complete a separate form for each pet)

I authorize the release of a copy of the medical records for the above animal.

From:

To:

MILLERSPORT SMALL ANIMAL CLINIC, PLLC

3210 Millersport Highway

Getzville, NY?14068

Phone: (716) 688-9424????Fax: (716) 688-7283

Pet Owner Signature

Date

Check here if this is a permanent transfer and you no longer wish to receive mailings from pervious hospital.