Record Release Form

Client Authorization for Release of Veterinary Medical Records
Pet Name

First NameLast Name
Client Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I hereby authorize Onalaska Animal Hospital to release the medical records for the above-named pet(s) to the following entity:
Would you like to make a change to your Onalaska Animal Hospital account status?
Receiving Clinic/Facility:
Fax Number / Email Address:
Phone Number (optional):
Delivery method
Purpose of release
I understand that this authorization applies only to the records requested at the time of signing. Onalaska Animal Hospital will not release records beyond those specified without additional authorization. I understand that record requests may take 24 to 48 hours to process, and I agree to allow this time for Onalaska Animal Hospital to prepare and release the requested records.
Signature
Date

MonthDayYear
Date
Should be Empty:

Client Authorization for Release of Veterinary Medical Records