Medical Records Release Form 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 NumberDate Date Format: MM slash DD slash YYYY AddressCityZipPatient 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 friendsAdditional 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 PhoneCell PhoneWork PhoneEmailI 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