Records Release Form

VirtuaVet Release of Medical Records

Download to your computer, fill out,and email or fax your VirtuaVet Release of Medical Records here.

Request for Release of Medical Records

From:  __________________________

To: ____________________________

I request that copies or summaries, as required by state law, of the medical records pertaining to my animal(s) named ____________________________________________  be released to Dr. Truli at VirtuaVet, preferably via email at VirtuaVet@BostonBrainBank.com, or by fax: 888-377-3332.

Payment of $_______________ is enclosed as payment of the fee required to photocopy and mail this information as directed.  (No fee required by VirtuaVet; check with your current veterinarian regarding their policies).  I hereby authorize and provide my written consent to this transfer of medical information.

____________________________                   ____________

Signature of Owner or Authorized Agent                    Date

************************************************************************

_____________________________________                      ____________

Signature of Veterinarian Who Approves This Request                     Date

Download VirtuaVet's Medical Release Form