Fillable Veterinary Medical Record Release Form printable pdf download

Veterinary Medical Record Release Form

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Beach Pet Hospital

316 N. Great Neck Rd

Virginia Beach, VA 23454

(757) 428-3251 phone (757) 496-6493 fax

Veterinary Medical Record 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:_________________________________________________________________

□

Medical records and/or Doctor’s notes for insurance purposes (list provider)__________________________

I ______________________________________ the undersigned do hereby grant my permission for the release

of any or all of the information contained in the medical records of those pets listed below to the above person

or Veterinary practice. Pet name(s) for release of medical records:

______________________________________

__________________________________________

______________________________________

__________________________________________

______________________________________

__________________________________________

______________________________________

__________________________________________

I understand that the original records will remain on file here.

This form remains in effect until notified in writing.

Check all that apply:

□

Please fax my pet’s records to:____________________________________________________________

Fax number:______________________________________________________________________________

□

Please mail or e-mail my pet’s records to:____________________________________________________

□

I am picking up my pet’s records today. If printed records exceed 10 pages, there will be a fee of 75 cents

per page.

□

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

reminders.

Please allow 24 hours for the preparation of all medical records.

Owner/Agent signature: _______________________________________________ Date:_________________

BPH Staff signature: __________________________________________________ Date:_________________

Veterinary Medical Record Release Form

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