Release of Medical Records Form Authorization for Release Of Medical RecordsClient:Horse:Date(s) of Service Requested (if known): MM DD YYYY Description of Information to be released: (check all that apply) Vaccine Record Laboratory Reports Radiology Films Most recent history and physical Entire Medical Record Other OtherThis information may be disclosed to and used by the following individual or organization: Name:Address Street Address City State / Province / Region ZIP / Postal Code Telephone NumberEmail This authorizes 3H Equine Clinic and Mobile Veterinary Services to release and disclose the above stated medical records. I understand that if I wish to revoke this authorization I must do so in writing and the written revocation must be signed and dated with a date that is later than the date on this authorization. This authorization will expire in 90 days from the date of this authorization unless I otherwise specify. This authorization will be in effect until MM DD YYYY Electronic Signature of Client*Date* MM DD YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
