Authorization for Release of Medical Records Authorization for Release of Medical Records Client Information Name * Email * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Cellular Phone * Secondary Phone Pet Information Pet's Name Species & Breed Pet's Name Species & Breed Pet's Name Species & Breed Release Pets Medical Records To Name of Veterinary Practice or Other Facility * Email of Veterinary Practice or Other Facility * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Phone Number * Fax Number Reason For Request * Relocation Referral to Specialist Second Opinion New Pet Adoption Pet Insurance Please Include Copies of Vaccination Records Radiographs Entire Medical Records Laboratory Results X-ray Reports I hereby certify that I am the owner or authorized agent of the owner of the above described pet(s). Further, I hereby request and authorize River Valley Veterinary Hospital to release the requested medical information for my pet(s). Check to certify * Yes Date * Submit
