Release of Medical Records

Request for Release of Medical Records
Client Full Name:

First NameLast Name
Client Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Client (myself)Veterinary practiceGrooming salonBoarding/Daycare facilityRescue groupOther
This request is pertaining to my animal(s) named:*
Medical notesVaccination due datesRadiographs/Ultrasound imagesGeneral patient informationLabwork resultsOther
complete history (start to recent)Specific date range:
Name of Recipient that has authorization for medical records:*
Email address of Recipient:
example@example.com
Fax number of Recipient:
Please enter a valid phone number.Format: (000) 000-0000.
I hereby authorize and provide my written consent to this transfer of medical information.

and

I authorize the release of medical records for the life of my pet(s), or until my permission is revoked in writing.
Signature of Owner or Authorized Agent*

Clear
Date*

MonthDayYear
Date
Should be Empty: