Request for Records | Mandarin AH

Request for Records | Mandarin AH
Requesting Clinic Information
Name of Person Requesting Records*
Clinic Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email*
example@example.com
Pet / Client Information
Pet's Name
Pet Parent's Name
Pet Parent Phone
Please enter a valid phone number.
Pet Parent E-Mail*
example@example.com
Check the box(es) to specify the information to be released/obtained. (At least one)

Vaccination HistoryLaboratory ResultsRadiographsComplete Medical RecordOther (please specify)
Additional Comments:
I hereby certify that I am the owner (Pet Parent) or authorized agent of the Pet Parent of the above-described pet(s). Further, I hereby request and authorize this veterinarian to release the requested medical information for my pet(s). I release the veterinarian and staff from any legal responsibility or liability for the release of information to the extent indicated as authorized herein. This authorization expires 90 days from the date of signature. I understand I may revoke this authorization, but the revocation may not be applied retroactively once the information specified herein has been released.
Today's Date*

MonthDayYear
Date
Should be Empty:

Requesting Clinic Information