I authorize and request the disclosure of all my pet veterinary medical information for the purpose of review and evaluation in connection. I expressly request that the designated record custodian of all covered entities under Confidentiality of veterinary patient records identified above disclose full and complete protected vet medical information including the following:

All vet medical records, meaning every page in my pet's  record, including but not limited to: office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency treatment, all clinical charts, reports, order sheets, progress notes, technicians's notes, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, statements, questionnaires/histories, correspondence. 

Please indicate

1. Your Pet's Name
2. Who will disclose the information and who will receive the information
3. What information will be disclosed
4. Where information may be disclosed and re-disclosed by the recipient
5. When the authorization will expire
6. Why the information is being disclosed
7. How a you may authorize and revoke disclosure of information