Record Release Form

Owner Name:   First Name    Last Name    Date: Date   
Address: Street Address    Address Line 2   City: City  
State: State   Zip:Zip   Phone: Phone Number   
Email: Email    

Patient Name: Name Species: Species   Breed:   Breed   
Date Of Birth:Date   Sex:Male   Male Nutered   Female   Female Spayed   

I authorize Name of Animal Hospital to release the above named patient’s medical records to:
Name: Name of Animal Hospital        
Address:   Street Address    Address Line 2    
City:City   State:State  Zip: Zip
Phone:Phone Number      Fax: Fax Number    
Email:Email    

If specific dates are needed, please indicate, otherwise the entire medical record will be sent. From:   Date   Through:  Date   

I hereby certify that I am the owner or authorized agent of owner of the above described pet(s). Further, I hereby request and authorize Birch Bark Veterinary Clinic to release/obtain the requested medical information for my pet(s). I release Birch Bark Veterinary Clinic and staff from any legal responsibility or liability for the release of information to the extent indicated as authorized herein. This authorization expires 30 days from date of signature. I understand I may revoke this authorization, but revocation may not be applied retroactively once the information specified herein has been released.

Please return signed and completed form via fax to (603) 712-5029 or email to info@birchbark.vet.