Medical Information Release Form

This completed form is required by law in order for us to release medical information. This information is kept secure, private and will not be shared with any 3rd party without your expressed consent.

Todays Date?*
MM slash DD slash YYYY
Owners Name on Record or Legal Representative*
First Last
Mailing Address of owner or legal representative (if different, otherwise leave blank)
Street Address Address Line 2 City State ZIP Code
Physical Address of owner or legal representative*
Street Address Address Line 2 City State ZIP Code
Mobile Phone Number of owner or legal representative*
Email of owner or legal representative*
Enter Email Confirm Email
Animal's name for which records are to be released.*
First
Species (choose one)*
Breed (please fill in)*
Sex (please choose one)*
Animal's Date of Birth*
MM slash DD slash YYYY
Name of person to release records to*
First Last
Email address of person to release records to*
Enter Email Confirm Email
Phone number of person to release records to*
Consent to Release Medical Information
I agree to to release ALL medical information on file. I understand part or partial medical information cannot be released, without the entire record released simultaneously. I also hold Rogue Equine Hospital and Rogue Companion Animal Clinic (or any DBA) harmless regarding the outcome and effects of releasing such information to the party as designated. I also understand that once released, Rogue Equine Hospital or Rogue Animal Clinic (or any DBA) is not responsible for any use of that information once in the possession of a third party as designated by me.
Checking the box for consenting and releasing all information contained in a standing medical record and signing will result in immediate release, once the receiver is properly identified as indicated on this form.
Signature of rightful owner or designated legal representative*
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Comments
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