Standing Operating Procedures
Medical Records Release
The client (owner) permits Fairview Heights Animal Clinic & Animal Hospital of O'Fallon to release their pet(s) medical record. In addition, any request for the client's pet(s) medical history may be sent to any veterinarian or boarding facility that is actively treating the client's pet(s) or has a "need to know".
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Yes - if yes, please write your name below
No
Client (Owner) Name
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First Name
Last Name
The client authorizes Fairview Heights Animal Clinic & Animal Hospital of O'Fallon to release their pet(s) vaccine history to (check all that apply)
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Grooming Business
Pet Boarding Facility
A Rescue or Human Society for canine/feline adoption
The client wishes to be contacted for any request that is made regarding their pet(S) medical records first.
Client (Owner) Signature
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Today's Date
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Month
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Day
Year
Date
Submit
Should be Empty: