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Medical Record Request Form

In order to release your pet’s medical records to another facility or person who is not listed as the responsible party on your pet’s account please submit this form. Our facility has 30 days to release requested medical records, however, we respect the fact that time may be of the essence in your pet’s need of having these records transferred. If you find that the recipient has not received your medical records in 7 days from submitting this form, please call us at 717-462-9480 so that we can work together to figure out why the transfer of records has been delayed. Please note that email of records is the fastest way to have records transferred.

Releaser Section

Pet Owner Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Pet's Name(Required)

Recipient Section

Name of Facility or Person to Whom We Have Permission To Release Records(Required)

Email Address of Facility or Person to Whom We Have Permission To Release Records(Required)

Phone Number of Facility or Person to Whom We Have Permission To Release Records(Required)

Mailing Address of Facility or Person to Whom We Have Permission To Release Records(Required)

Street Address Address Line 2 City State ZIP Code

Please note: As fax machines are not always reliable, please note that we email or U.S. Postal Service mail medical records. If you would like the record faxed, you are welcome to pick up the written records (we will need 72 hours notice for this) and fax them from your home.

Time Period

What dates of your pet's care do you authorize the records to be released?(Required)

My pet's entire record

Specific months of care

What are the specific months of records you authorize to be released?(Required)

Record Types

Which specific record types would you like released? (choose all that apply)(Required)

Vaccination Reminders/Due Dates

Laboratory Results

Prescriptions

Examination Notes

Diagnoses

All of the Above

Please note: We can not release records from other medical facilities, we can only release records of services and products provided by Healing Paws Veterinary Care, Inc.

What is the reason for this request?(Required)

Boarding or daycare requirements

Grooming requirements

New pet adoption application

Moving out of the area

Discontinuing Veterinary Care Relationship with Healing Paws

Other

Client feedback is important to us. Please briefly and respectfully share with us why you are transferring your pets' care to another facility. If you would like to discuss these reasons in person, please reach out to our client experience coordinator Jessica at [email protected]!

If other, please briefly explain(Required)