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.
I hereby authorize Onalaska Animal Hospital to release the medical records for the above-named pet(s) to the following entity:
Receiving Clinic/Facility:*
Fax Number / Email Address:*
Phone Number (optional): *
Purpose Of Release (check all that apply):*

Second opinion / referralBoarding or groomingTransfer of care to new clinicPerson copyOther
Delivery method*

EmailFaxPaper Copy (pick-up)
I understand that this authorization only applies to the records requested at the time of signing and that Onalaska Animal Hospital may not release records beyond what is specified without additional consent.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Client Authorization for Release of Veterinary Medical Records