Release of Medical Records

please complete the form below

CLIENT INFORMATION

First Name

Last Name

Address

City

Zip Code

Phone

PET INFORMATION

Name

Breed

I hereby certify that I am the owner or authorized agent of the owner of the above described pet(s) and am at least 18 years of age or older. Further, I hereby request and authorize Folsom Ranch Veterinary Hospital and Urgent Care to release the requested medical information for my pet(s) to the following veterinary clinic(s), insurance companies and/or boarding/grooming facilities:

I release Folsom Ranch Veterinary Hospital and Urgent Care and their veterinarians/staff from any and all legal liability for the release of information to the extent indicated and authorized herein. I may revoke this authorization to release records in writing, to Folsom Ranch Veterinary Hospital and Urgent Care, at any time.

CONSENT

I am over 18 years of age and am the authorized owner and-or guardian for the aforementioned patient. I authorize Folsom Ranch Veterinary Hospital and Urgent Care (FRVH) to perform treatment/procedure(s) on my pet(s) as recommended by FRVH's Veterinarians and employees. I was informed of the reasons for the treatment/procedure(s), along with the expected benefits and risks involved. I confirm that by signing below, I understand the inheritable and sometimes unforeseen risks associated with veterinary care and release all liability, without exceptions, from Folsom Ranch Veterinary Hospital (FRVH) while treating my pet(s). I understand that payment is required for all services at the time they are rendered unless prior arrangements have been made with hospital management. I understand that deposits may be required prior to certain procedures. In the event that a refund is due and the original payment is a credit card, the refund will be posted against the original credit card. I also authorize FRVH to use pictures of my pet(s) for learning or marketing purposes. Consent will apply to all future pets added to this account unless and until I provide a written revocation of that consent.

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