Owner's Name *

First

Last

Spouse/Other *

First

Last

Street Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Please Choose One *

Cell
Phone

Phone *

Please Choose One *

Cell
Phone
Decline Email

Email Address *

How did you hear about is? *

Authorization to Release Veterinary Records

In accordance with the Veterinary Practice Act regarding the confidentiality of patient medical records, a written authorization or other form of waiver executed by the client or an appropriate court order or subpoena is required in order for St. Matthews Animal Clinic to produce copies of your pet’s medical records. Medical records released shall not contain any financial information of the owner. Only medical treatment records shall be released.

Upload Pet Records

Click or drag a file to this area to upload.

If you have a digital copy of your pet's records, please upload here.

Pet Name *

Breed *

Pet Name

Breed

Pet Name

Breed

I give permission for my pet’s picture to be used on SMAC’s social media *

Yes
No

I certify that I am the sole and rightful owner of the patient or that I am acting as a legal agent for the owner. I understand that full payment is due at the time service is rendered.

Date

Name

By typing your name, you are agree to all terms & condition listed out on this form.

Online Forms

New Client
Form

New Client Form

Authorization to Release Veterinary Records

I certify that I am the sole and rightful owner of the patient or that I am acting as a legal agent for the owner. I understand that full payment is due at the time service is rendered.

Book an Appointment

Have a Question?

Location

Contact Information

Hours

Online Forms

New ClientForm

New Client Form

Authorization to Release Veterinary Records

I certify that I am the sole and rightful owner of the patient or that I am acting as a legal agent for the owner. I understand that full payment is due at the time service is rendered.

New Client
Form