Authorisation to Share Vet Records Form

Authorisation to Share Records

Client details

Please provide your details here.

Please ensure these details match those at your vet practice (or other professional). If you need to update your records at the other practice (e.g. to change a maiden name to a married name, or for a house move), please do this BEFORE we contact them for your records!

Client Name(Required)

First Last

Client Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Name(s) of Dog(s)(Required)

Professional details

Vet practice or other professional for which authorisation is being given.

Professional Name(Required)

Professional's Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Professional's Phone Number(Required)

Professional's Email(Required)

example@example.com - If you're not sure, please check with your vet - the form will not submit without a valid email address.

Authorisation

For the purpose of providing effective support, I authorise:

The above professional to provide copies of my dog’s records to Canine Thinking (both historical and in the future during a behaviour and training programme).
Canine Thinking to provide information from my dog’s behaviour and training records to the above professional.
Canine Thinking and the above professional to speak directly about my dog

Please tick to confirm;(Required)

I consent to the above professional sharing records with Canine Thinking.

Date(Required)

Signature(Required)

(if you're not on a touch screen device, you can use your mouse to draw your signature in the box!)

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