Grants Lick AH - Record Release

1
IN ACCORDANCE WITH THE VETERINARY PRACTICE ACT REGARDING THE CONFIDENTIALITY OF PATIENT MEDICAL RECORDS, “A WRITTEN AUTHORIZATION EXECUTED BY THE CLIENT OR AN APPROPRIATE COURT ORDER OR SUBPOENA” IS REQUIRED IN ORDER FOR OUR CLINIC TO RELEASE COPIES OF YOUR PET’S MEDICAL RECORDS.
2
Owner Name
Name of (Pet) or (all Pets) that the records for, be released
Phone number you can be reached
Please Select
Please Select
To be picked up by me or a family member
To be faxed
To be mailed
Please Specify
3
If to be faxed to, please specify
Fax Number
at what time
4
If to be mailed to, please specify
Email Address
5
Signature * This field is required.
Clear
6
Date * This field is required.
Date
Year
Month
Day
Should be Empty: