Medical Records Request Form

Please be advised the client listed below requests a copy of his or her records to be sent to Brookfield. Please send records to myvet@brookfieldanimalhospital.com or fax records to (203)775-9496. If you have questions for the Brookfield team, you can reach them at the above email address or phone (203)775-3679.

Pet Owner and Patient Information

Pet owner, please fill in the fields below to assist your existing veterinarian with sending a copy of your pet(s) medical records to us. When through, press submit and we'll send them on your behalf. Alternatively, you may print the form and send it yourself.

Veterinarian Practice Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Veterinary Practice Phone Number*
Veterinary Office Email
We'll use this address to send your request to. Only enter an email address here if you are sure this is where medical record requests should be sent.
Your Name*
Please use the name that the medical file is listed under at your previous veterinarian's office.
First Last
YOUR Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
YOUR Phone*
YOUR Email*
Name (s) of the pet(s) whose medical records you would like sent to Brookfield.
Reason for Medical Record Request
Please use this space to tell your veterinarian why you would like your pet(s) medical records transfered to Brookfield.
Signature or typed name
By signing or typing your name below, you confirm that you are the owner of the pet(s) described above, that you are at least 18 years of age, and that you would like a copy of your pet(s) medical records sent to Brookfield Animal Hospital.
Captcha

Pet Owner and Patient Information

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