Medical Record Release

Medical records contain sensitive information about a pet's health and medical history and clients have a right to privacy and control over their pet's information.

To ensure that your pet's medical records are accessible to you and to those you authorize to have access to them, we require this consent form to allow us to release your pet's medical records to a specified third party.

I hereby authorize Paoli Vetcare to release my pet(s) medical records to the following third party:

Pet Parent Name (required) :

Pet Parent Address (required) :

Pet Parent Phone number (required) :

Pet Parent Email Address (required) :

Name of Pet(s) (required) :

Release Previous 12 MonthsRelease Entire Record

I understand my the medical records may include information about my pet(s) diagnosis, treatment, laboratory results, and other medical information, and that this information may be protected by state and federal laws.

By signing this release, I acknowledge that I have read and understood the terms of this authorization and that I voluntarily consent to the release of my pet's medical records to the specified third party.

Name of Third Party (required) :

Phone Number of Third Party (required) :

Email Address of Third Party (required) :