Medical Records Release Authorization

I,   First Name   Last Name   , authorize the release and transfer of medical records for my pet(s) indicated below. Unless otherwise stated release will include exam, summaries, vaccination history, lab, imaging reports, and radiographs.
Pet Information:
Name: Breed:   

Please and send to:
Indicate how you would like to have your records sent:
Please Select Pick-up Fax Emailed    


If requesting records be emailed, please provide email address: 
   Email    

Name:   
Hospital Name / Facility:   


      

I certify that I am the legal owner, or authorized agent for the legal owner. I release the South Bay Veterinary Hospital form any legal responsibility or liability for the release of information authorized above.