Medical Records Release Form in Nicholasville, KY | Animal Hospital of Nicholasville

In accordance with the Veterinary Practice Act regarding the confidentiality of patient medical records, “a written authorization or other form of waiver executed by the client or an appropriate court order of subpoena” is required in order for Animal Hospital of Nicholasville to produce copies of your pet’s medical records.Medical records released shall not contain any personal or financial information of the owner. Only medical treatment records shall be released.
Name
First Last
Phone Number
Date
Date Format: MM slash DD slash YYYY
Address
City
Zip
Patient Names:
I hereby authorize the release of my pet’s medical records to:
Veterinary Clinics or Hospitals, Boarding/Grooming Facilities, Animal Control Specific Family members or friends
Additional Comments:
Please check below where we have your permission to leave a confidential message (e.g. lab or test results, prescription information, etc). Leave the space(s) blank if you do not wish to receive messages.
Home Phone
Cell Phone
Work Phone
Email
I certify that I am the sole and rightful owner of the patient or that I am acting as a legal agent for the owner.
Client Signature

Medical Records Release Form