Authorization for Release of Information

By agreeing to these terms, you (“The Patient”) hereby authorize and agree that The Pet Vet (“The Provider”) may discuss and/or disseminate The Patient’s personal health information (PHI) to, and receive that information from, the following individuals and/or entities as described below.

Patient Information Collected

When you engage our services, we may collect the following personal information:

Provider Information

Information Disclosure & Sharing

The Provider may disclose, receive, share, and/or discuss information with authorized agencies, organizations, schools, medical facilities, or persons as needed for treatment, payment, or healthcare operations. Such entities will be identified by name and relationship at the time of disclosure.

Types of Information That May Be Disclosed

By consenting to these terms, you acknowledge that the following categories of information may be shared with authorized individuals or entities:

• All health information
• Billing information
• Consultation reports
• Diagnostic test reports
• Discharge summary
• EKG/Cardiology reports
• History/physical exam
• Lab results
• Mental health records
• Operation reports
• Past/present medications
• Pathology reports
• Patient allergies
• Physician’s orders
• Progress notes
• Radiology reports and images

Additional categories of information may also be disclosed as relevant to your care.

Revocation & Consent Terms

You may revoke this authorization at any time by providing written notice to The Provider. You understand that the revocation will not apply to information that has already been released in response to this authorization.

You understand that authorizing the disclosure of information is voluntary. You are not required to sign this form in order to assure treatment. You understand that you may inspect or obtain a copy of the information to be used or disclosed. You understand that any disclosure of information carries with it the potential for an unauthorized redisclosure, that the information may not be protected by federal confidentiality rules, and that The Provider is not liable for any such redisclosure.

Finally, you understand that The Provider may refuse to share your information with the authorized individuals/entities named above if, in The Provider’s discretion, doing so would not be in the best interest of The Patient. If you have questions about disclosure of your information, you may contact The Provider at support@thepetvet.com.

Credit Card Authorization

When you provide your credit card information to The Pet Vet, you authorize us to charge your credit card for agreed-upon services. This authorization will remain in effect until canceled. You may cancel this authorization at any time by contacting your provider.

Information Collected

For payment processing purposes, we may collect the following credit card information:

Acknowledgment of Receipt of Privacy Practices Notice

By accepting these terms, you hereby acknowledge that you have reviewed and received a copy of this office’s Notice of Privacy Practices explaining:

• How this office will use and disclose your protected health information
• Your privacy rights with regard to your protected health information
• This office’s obligations concerning the use and disclosure of your protected health information

You understand that the Notice of Privacy Practices may be revised from time to time and that you are entitled to receive a copy of any revised Notice of Privacy Practices upon request.

Patient Consent for Specified Documents

By accepting these terms, you (“The Patient”) hereby acknowledge that you have reviewed, agreed to, and received a copy of the specified documents provided by The Pet Vet (“The Provider”), including but not limited to these Terms of Service and Privacy Policy.

You understand that if you have any questions, you may contact The Provider at support@thepetvet.com.

By accepting, you confirm the following:

• You agree and consent to the terms outlined in this document.
• You are at least 18 years of age or the age of consent for treatment in your state.

Contact Information

If you have any questions about these terms, your privacy, or any of the policies described above, please contact us: