Consent for File Release or Transfer Form

Welcome to Gateway Veterinary Services! We look forward to taking amazing care of your beloved pet. Please fill out the form below before your appointment so we can get to know you and your pet(s). We’re here to provide a calm, relaxing experience for your family.

Date *

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Cell Phone *

Home Phone

Clinic Name *

Clinic Address *

Indicate town and province only

Clinic Phone *

Patient Information

Pet Name *

Species *

Breed *

Sex *

Age *

Pet Name

Species

Breed

Sex

Age

Pet Name

Species

Breed

Sex

Age

As owner, or authorized agent of owner, I give permission to have all files for said animals to be forwarded to the company as required. Email is preferred to theteam@gatewayvet.ca *

I give permission to have files forwarded

Additional Comments

Consent for Electronic Disclosure: This is to confirm the client's request and consent for the enclosed information, documents and/or other files and attachments to be provided to Gateway Veterinary Services Prof. Corp. for their use as needed, at the designated fax or email as provided. Gateway Veterinary Services Prof. Corp. retains a copy of this document for the client/patient records. *

I confirm

Signature *

Patient Information

Address

Business Hours

Contact Info

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