Veterinary Medical Records Release Form

Client Name: ______________________________

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 following person or Veterinary practice:

Pet Name(s) For Release Of Medical Records

1. _______________________

2. _____________________

3. _______________________

4. _____________________

Release Records to: _________________________________________

Date: _________________

Fax # ____________________________

Reason For Request Of Records:

_________________________________________

_______________________________

Client Signature

Date

__________________________________

___________________________

TVC/CSP Staff Witness

Date

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Parent category: Legal