Record Transfer Request -

In accordance with the Veterinary Practice Act regarding the confidentiality of patient medical records, “a written authorization or other form of waiver executed by the client or an appropriate court order or subpoena” is required in order for us to provide a copy of your pet’s medical records.

I certify that I am the owner of the patient(s) named below or that I am acting as a legal agent for the owner.

Patient/Pet Name*

Client Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Record Release Consent*

I hereby authorize Flanary Veterinary Clinic, PLLC, to release my pet’s medical records to groomers, boarding facilities, other veterinary clinics and state health officials as needed.

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Record Transfer Request

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