Authorization For Release Of Medical Records printable pdf download

Authorization For Release Of Medical Records

Princeton Animal Hospital & Carnegie Cat Clinic

726 Alexander Rd.

Princeton, NJ 08540

Authorization for Release of Medical Records

Form A

Pet(s) Name:___________________________________________________________________

I authorize Princeton Animal Hospital & Carnegie Cat Clinic to release medical records to the

following businesses/individuals upon request (example: kennels, groomers etc.):

______________________________________________________________________________

Company Name

______________________________________________________________________________

Street Address

City

State

Zip

______________________________________________________________________________

Company Name

______________________________________________________________________________

Street Address

City

State

Zip

Please initial below to authorize release to any township requesting medical record information

for licensing. By choosing not to initial at this time, you will be required to complete additional

authorization forms when medical records are requested for licensing.

____

I authorize release of medical records to any township requesting information for

licensing

Initial below to allow us to release information to requesting adoption agencies. By initialing,

this will allow us to release information to requesting adoption agencies without having to obtain

a written consent from you first.

_____ I authorize release of medical records to adoption agencies

_________________________________________________

___________________

Signature of Owner

Date

Authorization For Release Of Medical Records