Consent for Medical Records Release

(Vaccine History/Referral Info only)

 

In accordance with the Veterinary Practice Act regarding the confidentiality of patient medical records, “a written authorization or other form of waiver executed by the client or an appropriate court order subpoena” is required in order for a veterinary clinic to release copies of your pet’s medical records. 

Please see the following request and signed consent:

 

I certify that I am the sole and rightful owner of the patient or that I am acting as legal agent for the owner.

Patient Name (s):______________________________________________________

Client Name:_________________________________________________________

Address:____________________________________________________________

__________________________________________________________________

Phone:_____________________________________________________________

Email:____________________________________________________________

 

I hereby authorize the release of my pet’s vaccination history on request by boarding kennel, groomer, or veterinary clinic and release of medical info to referral specialists working at the recommendation of Edgewood Animal Clinic.

 

__________________________________________           ________________________

Client signature                                                                             Date