Vaccination & Medical Record Release Authorization Form

I, the undersigned, do hereby authorize The Kalona Veterinary Clinic to release all Vaccination Records of my pets listed below to requesting boarding, and grooming facilities:

I, the undersigned, do hereby authorize The Kalona Veterinary Clinic to release all Medical Records of my pets listed below to veterinary facilities as needed for medical and/or surgical treatment:

In addition, I authorize the following person(s) to release the records of these pets, as listed above, in the event that I am unable to do so:

This authorization expires one year from the date below

All veterinary medical records are considered privileged and confidential. According to Iowa State Law (Chapter 811 12.4(2)) records will not be released except by court order or the consent/request of the owner or any authorized individual of the patient(s).

It is with our utmost respect not to share any client-patient confidential records without your permission. By signing and agreeing to this form this gives us the permission to release any medical information listed for the above named patient(s).