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Medical Records Release Form - Powell Animal Hospital - Powell, TN

Powell Animal Hospital

205 Star Mountain Way (Formerly500 W Emory Rd)
Powell, TN 37849

(865)938-1884

powellanimalhospital.com

Medical Records Release Form

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Pet's Name (required)
First Name (required)
Last Name (required)
Species (required)

Dog
Cat


Breed (required)

Sex (required)

Male
Female


Age (required)

Color (required)

From (party requesting a copy of medical records): (required)

To (practice name and address with patient records): (required)

Records Release Authorization
I request that copies or summaries, as required by state law, of the medical records pertaining to my animal be released to the following veterinary practice or other party by fax or surface mail or by email
I have read the above and - (required)

I agree
I disagree


Fax number of recipient (required)

Email address of recipient (required)

Please include copies of: (required)
Vaccination Records
Exam Reports
Pathology/Biopsy Reports
Laboratory Reports
Surgery Reports
Radiology/X-Ray Reports
Entire Medical Record
I hereby authorize and provide my consent to this transfer of medical information

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