Please choose a location*

Kirkland
Newcastle/Renton

Today's Date*

Owner's Name*

First Last

Contact Number*

Name of pet(s)*

I authorize Eastside Veterinary Associates to release*

Select All
Immunization Records (Daycare, Boarding, Grooming, Trainer)
Medical Records (Send records to Specialist, another practice, Owner)

If you selected 'Medical Records' above please specify the purpose of release*

Continuing Care/Specialist
Transfer to another provider
Insurance
Personal use
Other

If you selected 'Transfer to another provider' above please let us know what you'd like us to do with your account*

Please keep my account active to continue to receive reminders for my pet
Please inactivate my account so that I no longer receive reminders for my pet

Records to be released to:*

E-mail to receive medical records*

I hereby certify that I am the owner or authorized agent of the owner of the above-described pet(s). Further, I hereby request and authorize Eastside Veterinary Associate to release the requested medical information for my pet(s). I release Eastside Veterinary Associates and their veterinarians and staff from any and all legal liability for the release of information to the extent indicated and authorized herein. I may revoke this authorization in writing at any time. This authorization expires within (6) months of the date of the authorization.*

Signature of Legal Owner:

First Last

Medical Records Release Form