Medical Record Transfer Request Form

Name: Highlands Pet Hospital
Address: 2550 Highlands Rd W, Lethbridge, Alberta, T1J4V3, Canada
Telephone: 403-327-7387
Price range: $

APPOINTMENT

Complete this form before your visit.

Clinic Name *

Clinic Phone Number *

Clinic Email Address *

Name *

First

Last

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Email *

Telephone *

Second Telephone

Third Telephone

Patient(s) to be transferred *

Please email the above file(s) as per the client's request. *

Signature *