Medical Record Request Form Medical Record Release Releaser Section Pet Owner Name * Pet Owner Name First First Last Last Address * Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Phone * Email * Pet's Name * Recipient Section Name of Facility or Person to Whom We Have Permission To Release Records * Email Address of Facility or Person to Whom We Have Permission To Release Records * Phone Number of Facility or Person to Whom We Have Permission To Release Records * Mailing Address of Facility or Person to Whom We Have Permission To Release Records * Mailing Address of Facility or Person to Whom We Have Permission To Release Records Mailing Address of Facility or Person to Whom We Have Permission To Release Records Mailing Address of Facility or Person to Whom We Have Permission To Release Records City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Please note: As fax machines are not always reliable, please note that we email or U.S. Postal Service mail medical records. If you would like the record faxed, you are welcome to pick up the written records (we will need 72 hours notice for this) and fax them from your home. Time Period What dates of your pet's care do you authorize the records to be released? * My pet's entire record Specific months of care What are the specific months of records you authorize to be released? * Record Types Which specific record types would you like released? (choose all that apply) * Vaccination Reminders/Due Dates Laboratory Results Prescriptions Examination Notes Diagnoses Please note: We can not release records from other medical facilities, we can only release records of services and products provided by Healing Paws Veterinary Care, Inc. What is the reason for this request? * Boarding or daycare requirements Grooming requirements New pet adoption application Moving out of the area Discontinuing Veterinary Care Relationship with Healing Paws OtherOther Client feedback is important to us. Please briefly and respectfully share with us why you are transferring your pets' care to another facility. If you would like to discuss these reasons in person, please reach out to our client experience coordinator Jessica at jlambert@carlisleveterinarian.com! * Expiration Date In what time period from today's date do you want this record release to expire? * 30 days 60 days 90 days 6 months 12 months I authorize that I am the legally responsible owner of the above named pet. * I authorize I authorize that I am over 18 years of age. * I authorize Signature * signature keyboard Clear Date * reCAPTCHA Submit If you are human, leave this field blank.
