Prairie View Animal Hospital in DeKalb, Illinois

Prairie View Animal Hospital

24 Rich Road
Dekalb, IL 60115

(815)756-9976

pvahosp.com

If you would like us to send your pet's medical records to another animal hospital or business, please fill out the form below:

Click here if you would prefer to print it out & send it in to us instead.

Records Release Form

Name (required)

First Name (required)	Last Name (required)

Pet Name(s) (required)

Phone (required)
Phone Type	Phone Number (required)

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

E-Mail Address :

Reason for records release:

Please check any/all that apply. Please leave a detailed description below. (required)

Second opinion
Referral
Vaccine certificate for boarding, grooming, daycare, etc.
Change of veterinarian
Moving out of the area

Please provide any additional information about your records transfer here:

Where should we send the records:

Business Name: (required)

Contact information: Fax or e-mail only please. (required)

Please read:
I hereby grant my permission for the release of any or all of the information contained in the medical records of those pet(s) listed above to the veterinary practice or business that I have indicated. I understand that the original records will remain on file at Prairie View Animal Hospital for 7 years from the date of the last visit. This form will remain in effect until notified in writing. If I still retain a balance with Prairie View Animal Hospital, I understand that monthly finance charges will remain in affect and that if the account goes 120 days without a payment, my account will be turned over to the collection agency and a collection fee of 33% of the balance will be added.

Selection (required)

I agree/authorize the above
I do not agree/authorize the above

Please inactivate my chart. I will no longer recieve reminders for my pet.

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