Onalaska Animal Hospital - Client Authorization for Release of Veterinary Medical Records

Pet Name(Required)

First Last

Client Name(Required)

First Last

Client Email(Required)

Client Phone(Required)

Would you like to make a change to your Onalaska Animal Hospital account status?(Required)

Yes, inactivate account

No, leave my account as is

I hereby authorize Onalaska Animal Hospital to release the medical records for the above-named pet(s) to the following entity:

Receiving Clinic/Facility(Required)

Fax Number / Email Address(Required)

Phone Number (optional)

Purpose Of Release(Required)

Delivery method(Required)

Fax

Paper Copy (pick-up)

I understand that this authorization only applies to the records requested at the time of signing and that Onalaska Animal Hospital may not release records beyond what is specified without additional consent.

Signature(Required)

Date(Required)