Medical Records Release Form

Client Information

Owner Name

Phone Number

Email Address

Pet Information

Pet Name

Species / Breed

Clinic Currently Holding Records

Previous Clinic Name

Clinic Phone Number

Authorization to Release Records

I agree to the terms of service.

Medical Release Authorization

I, the undersigned, hereby authorize the above-named veterinary clinic to release any and all
medical records pertaining to my pet listed above to:
Family Pet Veterinary Center
West Des Moines / Norwalk, Iowa
Email (Preferred): [email protected] or [email protected]
Phone: 515-224-9747 (WDM) or 515-981-0317 (Norwalk)

This authorization includes, but is not limited to:
● Medical history and exam notes
● Vaccination records
● Diagnostic results (lab work, radiographs, etc.)
● Surgical and treatment records

Acknowledgment & Signature

I understand that:
● This authorization is voluntary and may be revoked at any time in writing.
● The receiving clinic will use these records solely for the purpose of providing veterinary
care.

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