Request for Release of Medical Records

Name: Veterinarian
Brand: Rose Veterinary Hospital

Client Name

(Printed name of party requesting a copy of their animals medical records)

Name of veterinary facility to contact for records

(Veterinary Clinic)

Phone number of facility to contact for records

I request that copies of the medical records pertaining to my animal(s) named

Name
	Name	Item weight

more items

Be released to the following veterinary practice, by fax:

Rose Veterinary Hospital
1910 High Street
Canon City, CO 81212
Fax Number of Recipient: 719.275.1179

I hereby authorize and provide my written consent to this transfer of medical information.

Signature of Owner or Authorized Agent

Sign above