Records Release Form
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Pet Name
*
Additional Pets:
Previous Vet Clinic (Name of practice)
*
Previous Vet Clinic Phone Number
*
-
Area Code
Phone Number
I hereby certify that I am the owner or authorized agent of the pet owner of the above-described pet(s). Further, I hereby request and authorize this veterinarian to release the requested medical information for my pet(s) to Family Pets Veterinary Care. I release the veterinarian and staff from any legal responsibility or liability for the release of information to the extent indicated as authorized herein. I understand I may revoke this authorization, but the revocation my not be applied retroactively once the information specified has been released.
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: