Medical Records Release 2025

Veterinary Medical Records Release Form

Bergen Veterinary Hospital 1154 Teaneck Road - Teaneck, NJ 07666

P: 201-837-3470 F: 201-353-3400
PRIMARY/AUTHORIZED PERSON NAME
I, the undersigned do hereby grant my permission for the release of any or all the information contained in the medical records of those pets listed below to the following person or veterinary practice:

Pet Name(s) For Release of Medical Records
1
2
3
4
Records to be released (check all that applies)
Release Records to
Fax
Email
example@example.com
Date Records needed by

MonthDayYear
Date
Reason for Request of Records
*** Please be advised that this form is required to be completed annually AND/OR the information to release records to is DIFFERENT than indicated on form.
PRIMARYAUTHORIZED PERSON SIGNATURE

Clear
DATE

MonthDayYear
Date
PRIMARYAUTHORIZED PERSON PRINTED
DATE

MonthDayYear
Date
Should be Empty: