Request for Release of Pet Medical Records

Request for Release of Medical Records
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Phone Number*

Area CodePhone Number
Today's Date*

MonthDayYear
Pet Name(s) ( Enter all requested)*
Release to:*
Business Name
Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Fax Number*

Area CodePhone Number
E-mail*
Reason for Medical Record Request*

MovingBusiness HoursPromotion2nd OpinionCost of ServicesQuality of ServicesOther
Comments:
We do our best to resolve any problems with clients in a personal and caring manner. Any client who experiences a difficult situation with our hospital is encouraged to talk with us directly so we can clear up the issue as soon as possible. We take pride in our dedication to the highest standards in veterinary medicine and all of our patients are very important to us. If you are requesting your pets medical records due to dissatisfaction with our service and would be willing to speak with us please click here.
I would like to be contactedNo I do not wish to be contacted
Please verify the following:
I understand that is is CVCC's policy is to provide the requested release within two (2-3) business days of the written request.
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 Carolinas Veterinary Care Clinic to release the requested medical information for my pet(s) to the above named facility(s). I release the Carolinas Veterinary Care Clinic and their veterinarians and staff from any and all legal liability for the release of information to the extent indicated and authorized herein.
Would you like for us to mark your pet as inactive? ( Choose this option if you will not be returning for services at CVCC)*

YesNo
Signature

First NameLast Name
Date

MonthDayYear
Should be Empty:

Request for Release of Medical Records