Request Records Form

Name: Northwest Animal Hospital
Address: 2024 S River Rd, Des Plaines, IL, 60018, United States
Telephone: 847-296-3112
Price range: $

Thank you for choosing Northwest Animal Hospital! Please fill out the form as completely and accurately as possible.

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Request Records Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 847-296-3112 for a faster response.

In accordance with the Veterinary Practice Act regarding the confidentiality of patient medical records, a written authorization is required in order for Northwest Animal Hospital to produce copies of your pet’s medical records. Medical records released shall not contain any sensitive personal or financial information of the owner. Only medical treatment records shall be released.

To request copies of veterinary records from the Northwest Animal Hospital, please complete this form. All fields are required. Please allow 2- 4 business days for completion. We may contact you via email or phone to verify your request. Thank you.

Client Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Pet Information

Pet Name *

Pet Name

Release Pet's Medical Records To An Animal Hospital:

Name of Veterinary Practice *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Fax

Select how you would like these records obtained: *

Please include copies of: *

Vaccination Records
Biopsy/Pathology Reports
Laboratory Results
Entire Medical Records

Legal Certification

I hereby certify that I am the owner or authorized agent of the owner of the above described pet(s). Further, I hereby request and authorize Northwest Animal Hospital to release the requested medical information for my pet(s).

Request Records Form

Request Records Form

Request Records Form

Pet Information

Release Pet's Medical Records To An Animal Hospital:

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