Authorization for Release of Medical Records & Image/Likeness of Pet
Evidenced by your signature below, you authorize the full release of any and all medical and veterinary records, correspondence, pictures, video, and any likeness of my Pet to be utilized by Veterinary Specialist Partners, and/or transferred to other veterinarians (including your primary veterinarian), scientists, or similar professionals, for the following purposes: diagnosis, treatment, or other care of your Pet; educational, including online forums and other presentations; statistical and scientific research; and, advertising for Veterinary Specialist Partners. You understand that medical information that is used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by federal or state law.
You, the undersigned, hereby release and discharge Veterinary Specialist Partners, LLC, and its employees and agents (the “Covered Entities”) from all liability relating to such use and/or disclosure, and agree to hold the Covered Entities harmless as to any use and/or disclosure made by him, her, or it in accordance with the provisions of this Authorization.
This Authorization shall be continuously effective from the date of signing until revoked in writing with delivery to the Covered Entities.
A photocopy of this Authorization shall be deemed effective as an original.