Authorization to Release Veterinary Records
Pet Owner Information
Owners Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet Information
Pet's Name
Pet's Species
Canine (dog)
Feline (cat)
Pet's Breed
The Information to be Released Includes
Full Medical History
Vaccination History
Current Vaccination Status Only
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.
Where would you like for us to send your pet's medical records?
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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