Medical Record Transfer - Erlanger Veterinary Hospital

Pet Owner Information

Name *

First

Last

Email Veterinary information

Email *

Address

Address Line 1

City

State

Zip Code

Pet Information

Pet's Name

Breed

Pet's Name

Breed

Pet's Name

Breed

Erlanger Veterinary Hospital has my permission to release information contained in the Medical Record of the above named pet(s). *

Yes
No

The information to be released includes: *

Entire Medical Record
Vaccination History Only

Erlanger Veterinary Hospital will provide the information requested above to the following party:

Name *

Address

Address Line 1

City

State

Zip Code

Phone

Fax

I hereby certify that I am the pet owner or authorized agent of the pet owner of the above described pet(s). Further, I hereby request and authorize Erlanger Veterinary Hospital to release the requested medical information for my pet(s) to the above named facility. I release the Erlanger Veterinary Hospital veterinarians and staff from any legal responsibility or liability for the release of information to the extent indicated as authorized herein. This authorization expires 90 days from the date of signature. I understand I may revoke this authorization in writing at any time, but the revocation may not be applied retroactively once the information specified herein has been released. *

I have read and agree to these terms.

Digital Pet Owner Signature *

Date *

*

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