Medical Release Form
Boulder Creek Veterinary Clinic
In accordance with the Veterinary Practice Act regarding the confidentiality of patient medical records, a written authorization is required in order for a veterinary animal hospital to release copies of your pet's medical records. Medical records released shall not contain any sensitive personal or financial information of the owner. only medical treatment records shall be released with your permission. Electronic Signatures. The parties acknowledge and agree that this permission and medical release form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via pdf) of an original signature.
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I agree
I do not agree
Client Information
Must match our records
Name
*
First Name
Last Name
Co-Owner Name
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Co-Owner Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Co-Owner Email
example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Forwarding Address (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet information
Pet Name
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Breed
*
Pet Name
Breed
Pet Name
Breed
Reason For Request
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Relocation
Second Opinion
Emergency Clinic
Pre-Authorization for future request
Referral to specialist
New Owner Transfer
Other
Pleas include copies of:
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Full Medical Record
Vaccinations
Exams
Labwork
Other
Release Pets Medical Information from:
Boulder Creek Veterinary Clinic 12870 Highway 9, Boulder Creek, CA 95006 831-338-7205
I hereby certify that I am the owner or authorized agent of the owner of the above described pet(s). Further, I hereby request and authorize Boulder Creek Veterinary Clinic to release the requested medical information for my pet(s). Signature
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Date
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-
Month
-
Day
Year
Date
Submit
Should be Empty: