Medical History Release Form

Name

Street Address

City

State

ZIP / Postal Code

In accordance with the Kentucky 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 or subpoena” is required in order for Bell County Animal Clinic 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.

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.

I hereby authorize the release of my pet’s medical records to:

Fax:

Date:

Signature