Authorization to Release Veterinary Records

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Name

This field is for validation purposes and should be left unchanged.

Please make a selection:(Required)

I would like to authorize Huntington Animal Hospital to OBTAIN my pet's records from another veterinarian

I would like Huntington Animal Hospital to RELEASE my pet's records to another hospital

Authorized Agent (Owner)(Required)

First Last

Patient Name(Required)

Current Veterinarian Info

Records are being requested to establish a full health history for an upcoming appointment with us at Huntington Animal Hospital, 113 Walt Whitman Rd. Huntington Station, N.Y. 11746 Fax (631) 423-7033 or huntingtonanimalhospital@verizon.net For any questions, concerns, or issues; please call (631) 423-7020.

Hospital Name(Required)

Hospital Address(Required)

Street Address Address Line 2 City State ZIP Code

Hospital Phone(Required)

Hospital's Email

Hospital's Fax #

Release my Pet's Records

Huntington Animal Hospital will release your pet's records to the following veterinary practice:

Hospital Name(Required)

Hospital Address(Required)

Street Address Address Line 2 City State ZIP Code

Hospital Phone(Required)

Hospital Email

Hospital Fax

Additional Information

Please send the Patient’s(Required)

Vaccination Records

Full Medical History

X-Rays

Lab Work

I release the Veterinarian and staff members from any legal responsibility and liability or the release of information to the extent indicated as authorized herein. For any questions, concerns, or issues; please call (631) 423-7020.(Required)

I agree and accept

Client Identifying Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Client ID Number

Patient Identifying Information

Name(Required)

Gender(Required)

D.O.B.(Required)

Breed(Required)

Client Signature

Date