Veterinary medical record release authorization form

Some clinics require a release be filled out before they relinquish medical records to other clinics. This form helps us quickly secure records in the event they have this policy.

Client Information

Client Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Email Address(Required)

Patient Information

Patient Name(Required)

Species(Required)

Breed(Required)

Age(Required)

Sex/Neuter Status(Required)

Referral Veterinarian Information (the clinic you are requesting records from)

Veterinary Clinic Name(Required)

Veterinarian Name(Required)

Clinic Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Clinic Phone Number(Required)

Clinic Email(Required)

Recipient Information

Animal Center for Emergency and Specialty (ACES)
5458 Buttonwood Dr. Madison, WI 53718
608-333-0500
Records should be emailed to office@acesvetmed.com

Records Requested (Please check all that apply):

Entire Medical Record

Vaccination History

Lab Results

Radiology Reports

Surgical Reports

Other

Please specify(Required)

Authorization I, the client listed above, hereby authorize the release of the above-specified medical records for my pet, listed above, to Animal Center for Emergency and Specialty. I understand that this authorization is valid for one year from the date of signature.

Signature(Required)

Date(Required)

Please Note:

This form must be completed and signed by the pet owner or legal guardian.
The veterinary clinic may charge a reasonable fee for copying and transferring medical records.
You may revoke this authorization at any time by providing written notice to the veterinary clinic.

Veterinary Medical Record Release Authorization Form

Veterinary medical record release authorization form

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