Authorization to Release Veterinary Records

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PLEASE EMAIL THE RECORDS REQUESTED BELOW AS SOON AS POSSIBLE

TO, FOX AND HOUNDS PET SERVICES, AS NOTED BELOW:

Attn:  Nikki Gagnon__________________________ Email: _________________________________

Pet Parent Information:

Name: ____________________________________________________________________________

Address: _________________________________________________________________________

City: _____________________ State: _________ Zip Code: _________ Phone: _______________

Pet Information:

Name: _____________________________________ Breed: _________________________________

Name: _____________________________________ Breed: _________________________________

Name: _____________________________________ Breed: _________________________________

Please include copies of (check all that apply):

þ Vaccination Records   □ Laboratory Reports   □ Exam Reports    □ Surgery Reports

□ Pathology/Biopsy Reports    □ Radiology/X-Ray Reports    □ Entire Medical Record ________________________

 (Date Range)

I hereby certify that I am the owner (Pet Parent) or authorized agent of the Pet Parent of the above-described pet(s). Further, I hereby request and authorize this veterinarian to release the requested medical information for my pet(s) to Fox and Hounds Pet Services. I release the veterinarian 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, but the revocation may not be applied retroactively once the information specified herein has been released.

 

 

PET PARENT SIGNATURE: __________________________________________ Date: ________________