Medical Release Authorization Form

First name

Last name

Phone

Pet Name(s):

Species / Breed:

Date of Birth (Pet):

Microchip #

Purpose of Release

I authorize Walnut Cove Veterinary Hospital to release medical records and/or discuss my pet’s medical history with the following individual(s), clinic(s), or organization(s):

Recipient Name / Clinic:

Phone #:

Email / Fax:

If Other, please specify:

Reason for Release

Referral to another veterinary provider

Boarding / grooming facility requirement

Owner Request

Other

If other, please specify:

Authorization

I understand that this authorization is voluntary and may be revoked at any time in writing. I acknowledge that once released, Walnut Cove Veterinary Hospital is not responsible for the privacy practices of the recipient.

Signature

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Date and time

Month

Day

Year

Time

HoursMinutes

Printed Name