Records Release Form

The Kentucky Board of Veterinary Medical Examiners requires veterinary hospitals to have written permission before releasing ANY information including vaccine history, blood testing, date of last examination, etc. Submission of this form is OPTIONAL. If you do not wish to have information on your pets released without being contacted first, DO NOT COMPLETE THIS FORM. Be aware that if we receive a request for information, you will be required to provide the hospital WRITTEN permission before information can be released.

Consent for the release of Pet Medical Records

Owner's Name(Required)

First Last

Phone Number(s)(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Pet Name(s)(Required)

Release of Information

(Please check the appropriate box(es))

I authorize Fort Thomas Animal Hospital to release information including diagnosis, records, and labwork of my above named pet(s) to ONLY the following:(Required)

Any Veterinary Hospital

Emergency Hospitals

Referral Specialists

Shelter/Rescue

Boarding Facility

Grooming Facility

Other Interested Party

Please indicate other interested party(Required)

THIS PERMISSION TO RELEASE INFORMATION WILL REMAIN IN EFFECT UNTIL TERMINATED BY ME IN WRITING

Signature(Required)

Date(Required)

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Records Release Form

Release of Information

Expert Veterinary Care in Fort Thomas, KY