Medical Record Release Form

Medical Record Release Authorization

I - 1. Authorize or 2. Do not Authorize - Country Friends Veterinary Clinic to release any and all medical information to an facilities, to include, but not limited to: boarding, grooming, other veterinary clinics and/or rescue groups, requesting said information on all pets both current and future. Please be aware that we must abide by properly requested release of pet records from law enforcement agencies.(Required)

Authorize

Do not authorize

Client Name(Required)

First Last

Today's Date

Email(Required)

Please list any additional names of persons (co‐owners) who are authorized to request release of records. (Name and your relationship to them)

I authorize the release of all records of all pets to Country Friends Veterinary Clinic.(Required)

I have read and understand.

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Phone

This field is for validation purposes and should be left unchanged.