Records Release Request

Medical Records Release Request
Owner/Authorized Agents Name *

First Name Last Name
Pet's Name *
Date *

Month Day Year
Date
I would like my pet's records transferred from: *
Office Phone Number *
Office Email *
example@example.com
Office Fax Number *
I would like my records transferred to: *
Office Name
Office Phone Number *

Area Code Phone Number
Office Email
example@example.com
Office Fax Number

Area Code Fax Number
I hereby certify that I am the owner or authorized agent of the owner of the above described pet. Further, I hereby request and authorize Hilltop Animal Hospital, to release the requested medical information for my pet to the following Veterinary Clinic(s) and/or boarding/grooming facilities.

I release Hilltop Animal Hospital, their veterinarians and staff from any and all legal liability for the release of information to the extent indicated and authorized herein. I may revoke this authorization in writing at any time.
Signature of Responsible Party *

Clear
Should be Empty:

Medical Records Release Request