Medical Record Request

I understand that my pet's records are confidential and cannot be disclosed without my written authorization. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected. I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon the authorization. The authorization will expire in 6 months or 1 year from the date of my submission, unless I selected indefinite or revoke the authorization prior to that time. I understand that it may take up to 5 business days for my record request to be fully processed and completed.

Please be aware that in order for us to release a patient's medical record, we must receive written consent from the mutual client before we can send it over to your facility. They can fill out this form on their end. Thank you for your understanding and cooperation.