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: ZipPhone: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 MacDonald Veterinary Services to release/obtain the requested medical information for my pet(s). I release MacDonald Veterinary Services 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 macdonaldvets@gmail.com