Prairie View Animal Hospital in DeKalb, Illinois - Form for release of medical records to PVAH

Prairie View Animal Hospital

24 Rich Road
Dekalb, IL 60115

(815)756-9976

www.pvahosp.com

If you would like us to obtain your pet's medical records from another animal hospital or business, please fill out the form below and send it to us via e-mail.

Click here if you would like to print it out & send it in yourself.

Records Transfer Form

Name (required)

First Name (required)	Last Name (required)

Pet name(s) (required)

Address
Street Address

City ,	State / Province	Zip / Postal Code

Phone (required)
Phone Type	Phone Number (required)

E-Mail Address (required) :

Record Transfer Details

Where should we request records from? (Business name & contact information) (required)

Authorization

Please read:
By marking below, I authorize the request of copies or summaries, as required by state law, of the medical records pertaining to my pet(s) as listed above, be released to Prairie View Animal Hospital via e-mail at pvah@frontier.com or via fax at (815) 758-1736.

I hereby provide my consent to transfer this medcial information: (required)

I Authorize
I Do Not Authorize

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Prairie View Animal Hospital
24 Rich Road, DeKalb, IL 60115
(815) 756-9976

Prairie View Animal Hospital
24 Rich Road, DeKalb, IL 60115 (815)756-9976 fax (815) 758-1736
e-mail: PrairieViewAH@gmail.com

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