Medical Records Release Authorization

Get Started

Medical Records Release Authorization

Please allow up to 48 hours to process this request. You will be notified by email when the records have been released.

Printable Version

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Name of your cat(s): *

The information to be released includes: *

Entire Medical Record
Current Vaccination Status Only
Other

I hereby certify that I am the owner or authorized agent of the owner of the above described cat(s). Further, I hereby request and authorize Atrium Cat Hospital to release the requested medical information for my cat(s) to the following veterinary clinic(s) and/or boarding/grooming facilities. *

I have read and agree.

Facility Name:

Phone Number:

Email Address:

I release Atrium Cat Hospital and its staff from any and all legal liability for the release of information to the extent indicated and authorized herein. I may revoke this authorization in writing at any time. *

I have read and agree.

Signature *

Date *