Medical Release Form

"*" indicates required fields

MM slash DD slash YYYY

Veterinary Medical Records Release Form

I, as named above, herby give my permission for the release of any or
all of the information contained in the medical records of the pet(s) listed on
account to be given to outside boarding, grooming, veterinary, pharmacy or
any specialty facilities upon request.

Reset signature Signature locked. Reset to sign again

Veterinarian Client Patient Relationship (VCPR)

The veterinarian client patient relationship (VCPR) is the basis for interaction
among veterinarians, their clients, and their patients and is critical to the
heath of your pet. Strong Veterinary Hospital requires every patient to be
examined by a licensed veterinarian on an annual basis* to maintain our
veterinary client patient relationship and to ensure the proper health of your
pet. Keeping your pet’s annual exam up to date yearly will allow us to
authorize prescriptions and food refills. I understand that once my pet is past
due for their annual exam, Strong Veterinary Hospital will no longer
authorize prescription medication and/or prescription food refills. Services
such as nail trims and anal gland expressions will be authorized as long as
your pet’s Rabies vaccination is current, even if annual exam is overdue.
Services provided during a technician visit do not count as an annual
exam/visit because your pet is not being seen by a veterinarian and no
examination is performed. Heartworm prevention refills will be authorized
with proof of current heartworm test on file as long as pet has been seen in
the past by a Strong Veterinary Hospital veterinarian.

*Some medications and illnesses require bi-annual visits

Reset signature Signature locked. Reset to sign again

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