Request for Release of Medical Records Form • Animal Hospital of Lake Villa

Pet Parent information *

First & last name, or name of your organization.

Pet Parent address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone number. *

Patient (pet) name? *

If multiple pets, please separate names with a comma.

Name of person or organization we are releasing records to? *

Would you like the records sent via fax, email, postal mail, or picked up at our facility? *

Email
Fax
Postal mail
Pick up

Email address we can send records to *

Fax number we can send records to. *

Address where we can mail records. *

Address Line 1

Address Line 2

City

State

Zip Code

We are open Monday-Friday, 8:00 AM-6:00 PM, Saturdays from 8:00 AM-1:00 PM. On Wednesday, we are closed from 1:00 PM - 2:00 PM for our weekly staff meeting.

Signature of owner (Pet Parent) or authorized agent. *

I hereby certify that I am the owner (Pet Parent) or authorized agent of the Pet Parent of the above-described pet(s). Further, I hereby request and authorize this veterinarian to release the requested medical information for my pet(s) cared for at the Animal Hospital of Lake Villa. I release the veterinarian and staff from any legal responsibility or liability for the release of information to the extent indicated as authorized herein. This authorization expires 90 days from the date of signature. I understand I may revoke this authorization, but the revocation may not be applied retroactively once the information specified herein has been released.