Authorization to Send Veterinary Medical Records

Authorization to Send Veterinary Medical Records

Authorize the transfer of your pet's medical records to a third party. Requests are typically processed within 24–48 hours.
Recipient Information

Receiving organization, clinic or person
Organization or Clinic Name
Put n/a if not applicable.
Contact Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Email
example@example.com
Client Information
Owner/Authorized Agent Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Pet Information
Pet(s)
Please include copies of:

Other
I hereby authorize Southside Mobile Veterinary Services to release the medical records and history of the patient(s) named above to the recipient specified in this form.

I understand that this release may include all clinical notes, laboratory results, and imaging. I acknowledge that once these records are released, Southside Mobile Veterinary Services no longer has control over the privacy or confidentiality of the information in the hands of the recipient. This authorization is valid for 90 days from the date of signature unless revoked by me in writing.
Owner/Authorized Agent
Today's Date

MonthDayYear
Date
Should be Empty:

Recipient Information