Authorization to Release Veterinary Records Logo
  • Authorization to Release Veterinary Records

  • Pet Owner Information

  • Pet Information

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

  • I release The Mitten Animal Clinic and 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.

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