Request for Release of Medical Records
From: ________________________________ (party requesting a copy of medical records)
To: _______________________________ (practice name and address with patient records)
I request that copies or summaries, as required by state law, of the medical records pertaining to
my animal(s) named ____________________________________________ be released to the
following veterinary practice or other party by fax or surface mail or by email:
______________________________________________________________________________
Name of Practice or Other Party
______________________________________________________________________________
Street Address City State Zip
Fax Number of Recipient ______________ Email address of Recipient __________________
Payment of $_______________ is enclosed as payment of the fee required to photocopy and mail
this information as directed. I hereby authorize and provide my written consent to this transfer of
medical information.
_________________________________________________ ___________________
Signature of Owner or Authorized Agent Date
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_________________________________________________ ___________________
Signature of Veterinarian Who Approves This Request Date