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PHONE: (304) 636-8363

1605 PARSONS ROAD
ELKINS, WV 26241

MONDAY – THURSDAY: 8AM – 5PM
FRIDAY: 8AM – 4PM

➤ Small Animal Hospital

Allegheny Equine Veterinary Service

Consent to Release Medical Records

Please fill out our online form or print, complete, sign, date, and mail the following Consent to Release Medical Records to:

Allegheny Equine Veterinary Service
P.O. Box 2116
Elkins, WV 26241

Consent to Release Medical Records PDF

Online Consent to Release Medical Records Form

  • Owner/Client Information:

  • MM slash DD slash YYYY

  • Pet/ Patient Information:

  • MM slash DD slash YYYY

  • Choose One or More of the options listed below.

  • New Owner Information:

  • Veterinarian Contact Information:

  • I certify that I am owner of the above described animal, and have authority to release medical records. I understand that a charge may be assessed for copies, fax and mailing at $2.00 plus $.25 per page. No charge will be assessed for email records.
  • Reset signature Signature locked. Reset to sign again
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

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Please note that you do not have an appointment until we have contacted you to confirm the date and time of your appointment.

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PHONE: (304) 636-8363

1605 PARSONS ROAD
ELKINS, WV 26241

MONDAY – THURSDAY: 8AM – 5PM
FRIDAY: 8AM – 4PM

➤ Small Animal Hospital
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