Authorization to Release Veterinary Records

Authorization to Release Veterinary Records

Ohio County Animal Clinic, PLLC - Hartford, KY
Owner's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number that can receive and send text messages.
Email*
example@example.com
Pet Information
Pet 1 Name*
Pet 1 Gender*
Pet 1 Species*
Pet 1 Breed*
Pet 2 Name
Pet 2 Gender
Pet 2 Species
Pet 2 Breed
Pet 3 Name
Pet 3 Gender
Pet 3 Species
Pet 3 Breed
Pet 4 Name
Pet 4 Gender
Pet 4 Species
Pet 4 Breed
Pet 5 Name
Pet 5 Gender
Pet 5 Species
Pet 5 Breed
Information to be released includes:*

Entire Medical RecordVaccinations History OlyCurrent Vaccinations Status Only
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 Ohio County Animal Clinic, PLLC to release the requested medical information for my pet(s) to the following Veterinary Clinics(s), boarding/grooming facilities, or other party.
Name of place or person records are being released to*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number to send records
Please enter a valid fax phone number.
Email Address of where to send records
example@example.com
I release Ohio County Animal Clinic, PLLC and their veterinarians and staff from any and all legal liability for the release of information to the extent indicated and authorized herein. I may revoke this authorization in writing at any time.
Signature

Clear
DateTime
Should be Empty:

Authorization to Release Veterinary Records

Pet Information