Medical Records Release Authorization Form – Texavet. All rights reserved

Medical Records Release Authorization Form/Formulario de autorización de divulgación de registros médicos

This form is to request records to be sent to someone else or directly to a business such as a boarding facility, clinic, or rescue. Este formulario es para solicitar que los registros se envíen a otra persona o directamente a una empresa, como un internado, una clínica o un centro de rescate.

I,*
First Name Last Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Pet Info*
Pet Name Pet Breed Pet Gender Pet Color
To the following person or entities:*
Name
Other Entity Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Other Entity Phone
Other Entity Email
Method Records Requested to Be Sent
- Email
- Mail
Authorize*
I agree that Texavet has my permission to provide any and all medical records about my pet
I release Texavet from any claim, cause of action, damage, penalty, liability of any kind or character related to or arising out of Texavet’s disclosure of my pet’s medical records to the aforementioned. I represent and warrant that I am the legal owner of the Pet named herein and have the authority to request disclosure of the Pet’s medical records.