Release of Records Authorization

Release of Records Authorization
I, First Name* Last Name* , the owner of Name(s) of pet(s)*, give my permission for the medical records pertaining to the above-named pet(s) to be sent to Name of Veterinary Clinic*.
Phone Number:*
Format: (000) 000-0000.
Email:*
Changing Veterinary ClinicsGoing for a second opinionGoing for boarding/groomingOther
Signature:*

Clear
Date*

MonthDayYear
Should be Empty: