Veterinary Medical Records Release Form

Bergen Veterinary Hospital

1154 Teaneck Rd

Teaneck, NJ 07666

(201) 837-3470 Fax (201) 353-3400

www.Bergenvet.com
Veterinary Medical Records Release Form
Client Name*
I, the undersigned do hereby grant my permission for the release of any or all of the information contained in the medical records of those pets listed below to the following person or veterinary practice:
Pet Name #1*
Pet Name #2
Pet Name #3
Pet Name #4
Records Release to:*
Date*

MonthDayYear
Date
Email*
Fax #
Reason for Request of Records*
Client's Printed Electronic Signature*
Date*

MonthDayYear
Date
Should be Empty: