Glencoe Veterinary Clinic: Client Release Form

Veterinary Medical Records
Release Form
Name

First NameLast Name
Email
example@example.com
I, (please print your name) do hereby grant 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:
Please list all pets in your care:
Option 1
This will allow Glencoe Veterinary Clinic to Release Records to: other veterinary clinics, boarding facilities, groomers, trainers, animal shelters
Signature
Date

MonthDayYear
Date
This release will remain in effect until you notify us in writing of any desired changes. ***

Option 2

I, the undersigned, do not wish to have any medical records released without my permission.
Client's Signature
Date

MonthDayYear
Date
I hereby give permission for Glencoe Veterinary Clinic to use my animal's photo(s) in marketing tools. I agree that Glencoe Veterinary Clinic may use such photographs of my animal(s) for any lawful purpose, including but not limited to: publicity, illustration, advertising and web content.
Client's Signature
Date

MonthDayYear
Date
Dr. Patty Dahlke • Dr. Paula Frick
605-13th Street West
Glencoe, MN 55336
320-864-3414 • 320-864-3616
glencoevetclinic@gmail.com
glencoevet.com
Should be Empty:

Veterinary Medical Records Release Form