Request for Transfer of Medical Records

SHERIDAN ANIMAL HOSPITAL
2288 Sheridan Drive • Buffalo, New York 14223
Telephone (716) 833-5345 • Fax (716) 833-8525

Request for Transfer of Medical Records

By 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. A separate form must be completed for each pet.

Client Name:*

Phone Number:*

Address:*

Email Address:*

Pet's Name:*

Species:*

Sex:*

Breed:*

Birthdate or Age:*

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

From: Sheridan Animal Hospital
Address: 2288 Sheridan Drive
Phone: (716) 833-2255
Fax: (716) 833-8525
Email: Email Us Online
Website: www.sheridananimalhospital.com

Today's Date:

To (Hospital):*

Hospital Phone:*

Hospital Email:*

Hospital Fax Number:*

Note: Sheridan Animal Hospital will email records to hospital within two business days of receipt of this request.

Is this a permanent transfer?
YesNo

If "yes" - owner acknowledges that we will no longer have a Veterinarian client/patient/doctor relationship at our hospital. This means you will no longer receive any future reminders and will be unable to receive any services, medications or prescription food from Sheridan Animal Hospital from this date forward.

Client's Electronic Signature:

Reason for transfer: