Pewaukee Veterinary Service Medical Records Request Form
Please complete all of the required sections for us to release a copy of your pets medical records
First Name *
Your answer
Last Name *
Your answer
Patient Name *
Your answer
Species *
Breed *
Your answer
Reason for Request *
I hereby request that copies or summaries of the medical records of my animal named be released to:
Veterinary Clinic or Facility Name *
Your answer
Address:
Your answer
Phone: *
Your answer
Email: *
Your answer
OR - I will pick up my records on (date)
MM
/
DD
/
YYYY
Owners Signature (by typing your name below you are authorizing Pewaukee Veterinary Service to release a copy of your Pets records) *
Your answer
Submit
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