Records Release Form
Release of Medical Records
Download to your computer, fill out,and email or fax your Truli Holistic 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, preferably via email at DrTruli@VetVMD.com, or by fax: 877-378-7854.
Payment of $_______________ is enclosed as payment of the fee required to photocopy and mail this information as directed. (No fee required by Dr Truli; 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
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_____________________________________ ____________
Signature of Veterinarian Who Approves This Request Date
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