Briar Patch Veterinary Hospital
706 Elmira Road
Ithaca, NY 14850
(607)272-2828
fax (607) 272-2875


Welcome to Our Site

Records Transfer Request

Please complete this form to authorize us to receive your pet's records from your previous vet, or to transfer them to a different practice.

Form - Records Transfer Request Form

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
E-Mail Address (required) :
Phone (required)
Phone TypePhone Number (required)
Pets name(s): (required)

Records are to be transferred as follows: (required)
From previous vet to Briar Patch
From Briar Patch to another vet

Name, phone, fax number of other vet practice. (required)


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