1 Start 2 Complete Authorization For Release Of Records There are several new laws in effect regarding release of patient records in veterinary medicine. We can no longer release records regarding your pet's health to anyone without your written consent. This means if your name is not on the account or written as an authorized release, we cannot give you any information. Please indicate below if you have anyone that you know who may need information regarding vaccination history, pet health, status, etc. Please note, if your pet is hospitalized, only people listed on this form can call and receive information in reference to the pet. Pet(s) Name * Please add a comma to separate each pet's name. Person or Facility 1 Person's or Facility's Full Name * Relationship to Pet's Owner * -Select-Family memberRescueGroomerVet clinicOther If Other Phone Number * Person or Facility 2 Person's or Facility's Full Name Relationship to Pet's Owner -Select-Family memberRescueGroomerVet clinicOther If Other Phone Number Person or Facility 3 Person's or Facility's Full Name Relationship to Pet's Owner -Select-Family memberRescueGroomerVet clinicOther If Other Phone Number Previous Veterinary records/Regular Veterinarian Clinic's Name Phone Number I am choosing to not list I am choosing to not list anyone on this form. My written consent is needed for anyone to find out information regarding my pet. Please note, because a person is listed on this form does not give them the authorization to make decisions regarding the health and care for your pet. Only the owner on the account will be able to make such decisions. If at any time records need to be released to anyone not listed, you must visit our hospital and sign another authorization for release of records form, specifically stating that person. Signature Signer Name * Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022
