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Veterinary Medical Record Release Authorization Form

Save time at your first appointment! Complete your required veterinary medical record release authorization form online before your visit.

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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 *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email Address *

Patient Information

Patient Name *

Species *

Breed *

Age *

Sex/Neuter Status *

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

Veterinary Clinic Name *

Veterinarian Name *

Clinic Address *

Address Line 1

Address Line 2

City

State

Zip Code

Clinic Phone Number *

Clinic Email *

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

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 *

Clear Signature

Date *

Name

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.

Forms

Veterinary Medical Record Release Authorization Form

Veterinary Medical Record Release Authorization Form

Client Information

Patient Information

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

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Contact Information

Location

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