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: Name: Breed:Name: Breed:Release 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 Faxed or mailed to information:Name: Hospital Name / Facility: Street Address Address Line 2 City State Zip Area Code Phone Number
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.