Release of Medical Records


Release of Medical Records

Thank you for considering Kentucky Paws Animal Hospital for your pet’s needs. Please fill out our Request for Release of Medical Records in its entirety to ensure we can provide you and your pet with the best possible care.
Please Note: Any fields with * are required.

I, the undersigned owner of the pets listed on this document, hereby request that the veterinarians and/or veterinary hospitals listed below (Releasing Party) release my pets’ medical records and information, including all charts, diagnoses, treatments, records, office notes, laboratory results, discharge summaries, orders and progress notes, pet insurance records, x-rays, ultrasounds, MRI, CT, or other scans to the Requesting Party herein. I hereby waive any privilege that I may have in such information, arising from state, federal, or common law or otherwise. This release shall be effective from the date signed and shall continue in effect indefinitely thereafter unless revoked by me. My records may be transferred, copied, or otherwise provided to the Requesting Party by email, fax, regular mail, or other electronic means.

All pets with records at releasing facility

Name of party requesting medical records (Requesting Party):

I authorize release to all boarders/kennels, groomers, and veterinarians making such requests at my veterinarian’s sole discretion.

Clear Signature