Records Release Form

Reason For Records Release

Second Opinion or Referral (please specify DVM)

Vaccination certificate for boarding, grooming, agility or obedience at

My Pet(s) will be in the care of ___ while I am away. I may be contacted at ___ to discuss medical needs. Payment is due at time of service. Please contact us to make payment arrangements.

Change of veterinarian (please specify)

Reason for changing provider

Reason Information

Name

First

Last

Pet's Name

Consent

I understand that the original records will remain on file here. I grant my permission for the release of any or all of the information contained in the medical records of those pets listed to the above person or Veterinary practice.

Check all that apply

Please fax a summarized printout of my pet’s records to:

Please mail a summarized printout of my pet’s records to:

I am picking up a summarized printout of my pet’s records today.

Please inactivate my chart. I know that the records will be retained for five years, but I will no longer receive reminders.

I will be needing photocopies of the medical notes at .75 cents per page. Please allow three days to process photocopies.

Summarized printout information

Owner's Signature

Today's Date

MM slash DD slash YYYY