Authorization of Veterinary Medical Records Release

                In accordance with the Veterinary Practice Act regarding the confidentiality of patient medical records, a written authorization is required in order for Northwest Animal Hospital to produce copies of your pet’s medical records.  Medical records released shall not contain any sensitive personal or financial information of the owner.  Only medical treatment records shall be released.

To request copies of veterinary records from the Northwest Animal Hospital, please complete this form. All fields are required. Please allow 2- 4 business days for completion. We may contact you via email or phone to verify your request. Thank you.

Client Name *
Client Name
Address *
Address
Phone *
Phone
Pet Information
Release Pet's Medical Records To An Animal Hospital:
Address
Address
Phone *
Phone
Fax
Fax
Release Medical Records to owner:
Fax
Fax
Select how you would like these records obtained: *
Please include copies of: *
Legal Certification