Home Records Release Authority Form

Records Release Authority Form

Records Release Authority

"*" indicates required fields

Name of Patient(s)*

Client First Name*

Client Last Name*

Client Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Client Phone Number*

I, as named above, authorize the release of my pet’s medical records to:

Name of doctor or hospital*

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Phone*

Signature*

Date*

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Name

This field is for validation purposes and should be left unchanged.