Veterinary Record Release Authorization Form
Please complete this form to authorize the release of your pet's veterinary records.
Owner's Full Name
*
First Name
Last Name
Owner's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Owner's Email Address
*
example@example.com
Pet's Name
*
Pet's Species
*
Please Select
Dog
Cat
Bird
Reptile
Other
Pet's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Veterinary Clinic Name
*
Veterinary Clinic Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Records to be Released
*
Medical History
Vaccination Records
Lab Results
Surgical Reports
Other
Authorization Signature
*
Date of Authorization
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: