Authorization to Release Medical Records

Authorization to Release Medical Records
Your Name*

First NameLast Name
Your Phone Number*

Area CodePhone Number
Your Email*
example@example.com
Pet's Name(s)*
Please list each pet this applies to. Separate with a comma.
Please send records to:*
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Email
example@example.com
By signing below, I authorize Mountain View Veterinary Health Center and give written consent to release vaccine records and other pertinent medical information on {petsNames} to {pleaseSend}. I certify I am the owner or authorized agent of the owner of the pet(s) identified above and that I am eighteen years of age or over.
Please Sign*

Clear
Agreement to remain in full force until

MonthDayYear
If no end date is selected then authorization will remain in effect until we receive written notification from you to end the authorization.
Additional Instructions
Please check here if you would like us to inactivate your account.

Please inactivate my account; I no longer wish to receive reminder communications from Mountain View Veterinary Health Center.
Should be Empty: