Records Release Form

Complete this form before your next visit.

Client's Name *

First

Last

Email *

Patient's Name *

Veterinary Client/Patient Information

In accordance with the principals of veterinary medical ethics as directed by the American Veterinary Medical Association (AVMA), the VCPR is the basis for interaction among veterinarians, their clients, and their patients. The VCPR exists when the veterinarian assumes responsibility for making clinical judgments regarding the health of the animal and has sufficient knowledge of the animal(s) to initiate treatment. To maintain a VCPR, a thorough examination of the patient must be performed within one year of any treatments or medications administered or prescribed. In accordance with the FDA Compliance Policy Guideline 7132.09 and Health and Safety Code Section 11400, we cannot return prescription items. Once these items have left the hospital we no longer have the assurance of the strength, quality, purity, or identity of the articles, and it is considered dangerous to return these items to shelf stock.

Medical Record Release

It has always been this hospital’s goal to show the utmost respect for our clients and patients. We take the medical records of your pet very seriously, following the strict guidelines set forth by the American Veterinary Medical Association (AVMA) and the California Veterinary Medical Association (CVMA).

We work to keep your records complete with detailed entries of the services and procedures administered to your pet, as well as entering notations, observations, and findings during your visit, and during client communications. It is our goal to maintain confidentiality and respect your privacy.

In order to comply with the current standards directing the release of veterinary patient medical records, we must have your written consent to transfer, copy or transmit either a portion or the entire medical history for your pet, from our hospital.

Consent for the Release of Medical Records

Please select all that apply

I authorize the Cardiff Animal Hospital & Wellness Center (CAHWC) to release/disclose my pet’s health and medical records to any veterinary facility that may request them.
I authorize the CAHWC to release/disclose my pet’s health and medical records to any grooming/boarding/pet care facility that may request them.
I authorize the CAHWC to release/disclose my pet’s health and medical records only to the facilities listed (specify below)
I do not authorize the CAHWC to release/disclose my pet’s health and medical records without prior consent.

I certify that I am the legal owner or authorized agent of the below patient (pet) and that I am authorized to sign authorizations for this patient. I understand that it is my sole obligation to notify CAH should I wish to change any portion of this document.

Signature *

Clear Signature

Date *