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
I,   Client Name * , request records for    Pet Name(s) *    or (all Pets) be released:
Type here Faxed to    Type here at    Time     Date
Type here    E-mailed to
Type here    Mailed to
Type here    To be picked up by me or a family member
3
Family Member Name and Relationship
4
Reason for record release
Kennel (Boarding)/Groomer
Continuity/Transfer of Care
Breeder/Rescue
Legal
Other
5
Client Phone Number
Area Code
Phone Number
6
Client Signature* This field is required.I understand this written release shall be effective from the date signed, regardless of reason, and shall continue in effect indefinitely thereafter unless revoked.
Clear
7
Date * This field is required.
Date
Year
Month
Day
Should be Empty: