Medical Records Release
Date
*
-
Month
-
Day
Year
Date
Pet Owner's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Patient's Name
*
I hereby authorize The Maywood Veterinary Clinic to release the above named patient's veterinary medical records, lab reports, and/or radiographs to:
*
Please list the name of the veterinary practice, insurance company, boarding facility, groomer, or other.
Email address or fax number of receiving party:
*
Are you transferring care to another veterinarian?
*
Please Select
YES
NO
Do you wish to inactivate your account with Maywood Veterinary Clinic?
*
Please Select
YES
NO
Do we have your permission to forward your records to other facilities in the future?
*
Please Select
YES
NO
Signature
*
Submit
Should be Empty: