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:

  • Name * Required
  • Address * Required
  • Pet/ Patient Information:

  • Sex * Required
  • Choose One or More of the options listed below.

  • Please send a copy of records to owner as listed above. * Required
  • Please forward/transfer all medical records to the new owner by: * Required
  • New Owner Information:

  • Name * Required
  • Address * Required
  • Please forward/transfer all medical records to the following veterinarian by: * Required
  • Veterinarian Contact Information:

  • Name * Required
  • Address * Required
  • 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.
  • Owner Name * Required