Authorization for Release of Medical Records

Authorization for Release of Medical Records

Client Information

Address *
Address
City
State/Province
Zip/Postal

Pet Information

Release Pets Medical Records From

Address *
Address
City
State/Province
Zip/Postal
Reason For Request *
Please Include Copies of

I hereby certify that I am the owner or authorized agent of the owner of the above described pet(s). Further, I hereby request and authorize River Valley Veterinary Hospital to release the requested medical information for my pet(s).

Check to certify *