Authorization to Release Veterinary Medical Records

Authorization to Release Veterinary Medical Records
Veterinary Hospital: *
Veterinary Hospital phone number and email:*
Owner Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Pet Information
Pet Name:*
Pet Name:
Pet Name:
Pet Name:
Pet Name:
Pet Name:
Please include a copy of all medical records including vaccination history, lab results, and any imaging.

I certify that I am the owner or authorized agent of the pet(s) listed above and hereby request and authorize the above veterinary hospital to release the requested medical information for my pet(s) to The Drake Center for Veterinary Care.
Owner Name:*
Owner Signature:*

Clear
Please forward to: Records@thedrakecenter.com
Should be Empty: