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


Briar Patch Veterinary Hospital

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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