South Shores Pet Clinic - Release Records Request Form

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Release Records Request Form
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FAX
TO
FROM
FAX
PAGES
PHONE
DATE
RE
CC
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Authorization to release records
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Please fax, mail, or e-mail the records for my pet(s) to South Shores Pet Clinic at (310) 832-1318 or e-mail to frontoffice@sspet.com
Pet's Name
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If you have any questions, please contact the South Shores Pet Clinic staff at (310) 832-5327 or me at
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Thank you for your prompt attention in this matter.
Sincerely,
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Printed Name
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Signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
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Email* This field is required.
example@example.com
Should be Empty:

Release Records Request Form