Requesting Records

Thompson Veterinary Clinic Medical Record Release Form

To comply with the American Veterinary Medical Association’s Principles of veterinary medical ethics regarding medical records, the Thompson Veterinary Clinic requires written consent by the owner to release summaries or copies of their pet’s medical records to another veterinary practice or interested party.

To facilitate this process, the Thompson Veterinary Clinic requires that you please use this Medical Records Release Form when requesting summaries or copies of your pet’s medical records. Once all required fields are entered press submit and we will receive your request at The Thompson Veterinary Clinic. Account must be paid in full prior to records being transferred.

* Indicates required field

Client Name *

First

Last

Client Email *

Client Phone Number *

I am requesting in writing, as required by state law, for the medical records pertaining to my animal(s) named below be released via method indicated on this form. *

Please choose the type of records being requested - See description (a) (b) to make choice. *

Digital Summary (A) Copies of Written Record (B)

(A) Digital medical record are computerized summaries of your visits and will be emailed to you or to the veterinary practice of your choice at no charge.

(B) Photocopies or facsimiles of the patient’s written medical records and lab reports will require a processing fee of $15 which will need to be paid prior to copies being made. Once we have received the signed form and payment we do require a processing period of up to 5 business days. Copies of the written medical records can be mailed, faxed, or emailed. *If the record requires special mailing such as FedEx - additional charges may apply.*

IF SELECTING (B) you will need to either provide your card information below or if you would like to call in payment please write "I will contact" or "Please contact me" in the credit card number section.

Credit Card Number *

Expiration Date *

CVV on back of card *

Card will be charged for the $15 plus an additional account balance prior to record transfer.

The following 3 questions are not required unless you are choosing to pay for copies. If you are requesting digital copies only, please move to the next section.

Where are we sending your records to?

Name of Practice or Other Party *

Practice or other party Email *

If mailing please include address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number of the Practice or other party *

Fax Number of the Practice or other party *

By typing signature box below, I represent I am the owner of the pet, or an agent authorized to act on behalf of the owner(s) of the pet. My agreement to the terms herein are binding against all other persons who may claim an interest in this pet. I also understand I am responsible for all changes attached to my account (if any) as well as record transfer fees. *Records will not be released until these charges are paid in full.*

Signature *

Date *