Authorization to Release Veterinary Medical Records

Previous Veterinary Hospital/Clinic Name:

Previous Veterinary Hospital/Clinic phone number, email address or fax number:

Owner Information

Name:

Address:

City, State, Zip: Phone:

Please send copies of: Vaccine Records, Office Notes/Medical records, Diagnostic results and Radiographs for all patients under this client.

I hereby authorize the above veterinary hospital/clinic, to release the medical records for my pet (s) to Dr. Sam’s Veterinary House Calls.

Patient (s) being seen by us on:

Owner’s Typed Name:

(Please accept owner’s typed name as their signature)

PLEASE EMAIL OR FAX THE REQUESTED RECORDS AS SOON AS POSSIBLE.

Phone: 484-809-9838 Fax: 888-276-9870 Email: officestaff@dr-sams.com

THANK YOU