Medical Record Transfer Form

Authorization to Release Veterinary Records

Pet Owner Information

Client Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Pet Information

Pet's Name *

Breed *

Add another pet? *

Yes
No

Pet's Name *

Breed *

Add another pet? *

Yes
No

Pet's Name *

Breed *

Union Pet Hospital has my permission to release information contained in the Medical Record of the above named pet(s). *

I have read and agree.

The information to be released includes *

Entire Medical Record
Vaccination History Only

Union Pet Hospital will provide the information requested above to the following party

Name *

Phone Number *

Fax

Address *

Address Line 1

Address Line 2

City

State

Zip Code

I hereby certify that I am the pet owner or authorized agent of the pet owner of the above described pet(s). Further, I hereby request and authorize Union Pet Hospital to release the requested medical information for my pet(s) to the above named facility. I release the Union Pet Hospital veterinarians and staff from any legal responsibility or liability for the release of information to the extent indicated as authorized herein. This authorization expires 90 days from the date of signature. I understand I may revoke this authorization in writing at any time, but the revocation may not be applied retroactively once the information specified herein has been released. *

I have read and agree.

Date *

Signature *

Clear Signature

Pet Owner Information

Pet Information

Union Pet Hospital will provide the information requested above to the following party

We provide exceptional pet care in Union, KY!

Address

Contact Us

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