Veterinary Medical Information Release

Veterinary Medical Information Release
Reason for Request
For Security and Identification please fill out the information of the PRIMARY Owner for your pet(s), who is registered in our system.
Primary Owner Name*

First NameLast Name
Primary E-mail*
Primary Owner Cell Number*

Area CodePhone Number
Patient Information
Patient 1*

Name Breed
Patient 2

NameBreed
Patient 3

Name Breed
What would you like transmitted?

Vaccine / PHC History OnlyComplete Medical RecordFill out a Reference Form or Questionnaire
Person or Organization to transmit the record to:

Please provide us with the applicable information below. Please note that most information will be emailed within 2 business days. All other transmissions may take substantially longer.
Name*
Email
example@example.com
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Please Read Carefully and sign below
- If you selected “Complete Medical Record” the information transmitted will be the complete database that we have on file for the patient. Even though we typically limit the scope to the specific reason the record needs to be transmitted, the data may include but is not limited to: any form you previously filled out, forms and record entries that contain your personal contact information, attachments from previous institutions and previous medical records, doctor’s notes, transcripts of phone conversations, treatment plans that may include financial information, saved invoices, etc.
- If you selected “ Vaccine / PHC History only”, our staff will disclose current and past vaccinations, PHC preventive health care information such as: test results for parasites, most recent physical exam findings, behavior observed in the veterinary hospital
- Reference Form or Questionnaire: If you need us to provide a reference for a Landlord, Groomer, Insurance Company, or Rescue, please upload the necessary form or questionnaire below. We will fill it out and send it back to you. Please note that our staff will not answer questions about you or your pet to a third party over the phone.
Please note that Veterinary Records are NOT subject to HIPPA laws. Also, in Virginia veterinarians are compelled to release Complete Medical Records to any Government Entity or Law Enforcement Entity upon request without notification to you, the owner.

I hereby direct the staff of Hilton Animal Hospital to release the Veterinary Record information as outlined on this form above. I certify that I am the legal owner of the above-listed pet(s). I release Hilton Animal Hospital and Staff from any legal responsibility or liability for the release of information in reference to this request.

This authorization expires 90 days from the date of signature. I understand I may revoke this authorization in writing any time, but the revocation may not be applied retroactively once the information specified herein has been released.
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First NameLast Name
Signature*

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Veterinary Medical Information Release

Patient Information

Person or Organization to transmit the record to: