Medical Records Release form

Medical Records Release form
Owner's name:*

First Name Last Name
Pet's name:*
Phone Number:*
Please enter a valid phone number.
My pet has been seen at the following clinics/hospitals for this issue:
I hearby authorize Twin Cities Animal Rehab + Sports Medicine Clinic access to my pet's medical records. Please release requested medical records and images to Twin Cities Animal Rehab + Sports Medicine Clinic via:

email: records@tcrehab.com

fax: (952) 224-9194

physical address:
12010 Riverwood Drive
Burnsville, MN 55337
ph: (952) 224-9354

Thank you,
Owner's signature:*

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Date:*

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