Client Record Release Form

Authorize the release of your pet’s medical records with the client record release form. Ensure accurate owner and pet details for a seamless process.

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Client Record Release Form Muskego, WI

Please ensure the accurate completion of the client record release form. Double-check all details, including owner and pet information.

Client Record Release Form

"*" indicates required fields

"*" In accordance with regulatory provisions of Wisconsin State Statute 453.075 and the Veterinary Practice Act regarding the confidentiality of patient medical records, a written authorization or waiver is required for us to provide a copy of your pet's medical records.

Owner’s Information

Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Pet’s Information

Pet's Name*

Species*

Cat

Dog

Sex*

Breed*

Date of Birth / Age*

Untitled*

I request and authorize Star Veterinary Center to release the above listed pet's medical records to:

Name of person or practice:*

Email or Fax Number*

Reason*

Untitled*

I hereby certify that I am the owner or authorized agent of the above named pet.

Agent’s Signature*

Date*

Name

This field is for validation purposes and should be left unchanged.

Client Record Release Form

Client Record Release Form Muskego, WI

Client Record Release Form

Owner’s Information

Pet’s Information

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