West Jefferson Animal Hospital

121 E. Main St.

West Jefferson, OH 43162

(Phone) 614-879-8250 (Fax) 614-879-8630

AUTHORIZATION FOR RELEASE OF VETERINARY MEDICAL RECORDS

West Jefferson Animal Hospital has set forth certain policies regarding the health and medical care of our patients. According to the American Veterinary Medical Association (AVMA), “Medical Records are the property of the practice and the practice owner. It must not be release except by court order or consent of the owner of the patient. Veterinarians should secure a written release to document that request.”

Client Name(s):_________________________________________________________________________

Address:______________________________________________________________________________

City:___________________________________ State:________________ Zip:______________________

Phone Number(s):_______________________________________________________________________

 

Pet Name_____________________________________________ DOB/Age:_______________________

Breed:_______________________________________________ Color:___________________________

Pet Name_____________________________________________ DOB/Age:_______________________

Breed:_______________________________________________ Color:___________________________

 

Please release a copy of my pet(s) veterinary medical records to:

 

Owner’s Name:________________________________________________________________________

OR

Veterinary Facility:______________________________________________________________________

Address:______________________________________________________________________________

City:___________________________________ State:________________ Zip:______________________

Phone Number:_______________________________ Fax Number:_______________________________

 

 

By my signature, I authorize West Jefferson Animal Hospital to release my pet(s) records.

 

_____________________________________________________________ ______________________

Signature of Owner or Authorized Person Date

 

*This release form will only be valid for 90 days from the date of the signature.