Animal Emergency and Trauma Center

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Request for Records or Radiographs

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Client Satisfaction Survey

Request for Records or Radiographs

Note: We will need personal contact before sending any medical information. Due to privacy regulations, we can only send medical information upon the request of the actual pet owner.

Name of client:
Name of pet:
Address:
Phone:
Email:
Date of Visit:
Family Vet:

Name of person requesting information if different from above.
Name:
Address:
Phone:
Email:
Relationship to Client:

What do you want sent? (radiographs, records, etc.)

Address to send radiographs or records:

Name of person or veterinarian where information is to be sent:

Address, Email or Fax:

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