Today's Date *

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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Applicable pet(s) name(s): *

Please select one *

I would like to have my animal’s previous records transferred to Central Vet
I would like to have my animal’s records from Central Vet transferred to another veterinary clinic or 3rd party organization

I authorize any agent of this organization to release any and all medical records, including but not limited to: results, x-rays, quality assurance reports, and any relevant information that may be deemed to be 'personal information' under the Personal Information Protection and Electronic Documents Act ("PIPEDA") for pet(s) owned by me to the veterinarians and agents of Central Veterinary Services. *

I authorize.

I authorize any agent of Central Vet to release any and all medical records, including but not limited to: results, x-rays, quality assurance reports, and any relevant information that may be deemed to be 'personal information' under the Personal Information Protection and Electronic Documents Act ("PIPEDA") for pet(s) owned by me to the veterinarians and agents of the following organization. * *

I authorize.

Please note the name of the veterinary clinic: *

Please note the name of the veterinary clinic or 3rd party organization (ie. boarding facility, groomer, doggy daycare, etc): *

Would you like the veterinary clinic or 3rd party organization to receive complete records or just vaccine due dates and any applicable certificates (ie. Rabies)? *

Full records
Vaccine due dates and certificates only

Would you like your animal’s file at Central Vet to remain open? *

Yes
No

The contents of the said medical records may also be discussed in person, over the phone, by fax, or e-mail as is necessary for the care of the above stated animal(s). *

I have read and understand

Signature *

Privacy of personal information is an important principle to Central Veterinary Services. In compliance with the federal Personal Information Protection and Electronic Documents Act (PIPEDA), we are committed to collecting, using, and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide. The primary purpose for collecting personal information is to provide veterinary services.

Authorization to Release Medical Records

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