Medical Records Request Form

Memorial-610 Hospital for Animals

910 Antoine Drive
Houston, TX 77024

(713)688-0387

mem610.com

Medical Records Request Form

This form is to request copies of medical records. Only clients or their legal representatives may make a medical record request. Memorial-610 Hospital for Animals may verify your identity.

Client Name (required)

Patient Name (required)

Species (required)

Address (required)

City (required)

State (required)

Zip (required)

Phone (required)

Description of information requested (mark all that apply):

Dates of Service

Dates (Start - End) (required)

Vaccination History

Laboratory Results

Imaging Reports/Studies (Radiographs, US)

Entire Medical Record

Purpose of Disclosure (select one):

Boarding/Grooming/Training

Moving to Another Veterinary Clinic/Hospital

Insurance Claims/Payment of Bills

Other

I want to request medical records to be sent to the third-party I have indicated below. My completion of this form serves as authorization for Memorial-610 Hospital for Animals to disclose these records to this person or group. I understand that once my information leaves Memorial-610 Hospital for Animals, Memorial-610 Hospital for Animals is no longer able to protect the information, and the recipients of my information may not be legally required to protect my information. I understand that if these records are to be printed and mailed, the request may be subject to a reasonable fee.

Name (required)

Address (required)

City (required)

State (required)

Zip (required)

Phone (required)

Fax

Email (required)

I understand this authorization may be revoked in writing at any time, except to the extent that action had already been taken in reliance on this authorization. This authorization expires

(insert date or applicable event)

on or within 365 days or the date of authorization, whichever is greater.

Signature (required)

Date (required)

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