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Client Record Release

Name*

First

Last
Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Phone*
Pet's Name*
Breed*
Sex*
Age / D.O.B*
I hereby certify that I am the owner or authorized agent of the above named pet(s). I hereby request and authorize this veterinarian to release the veterinary medical records for my pet(s) to:*
Reason:*

And release American Veterinary Hospital from any harm and responsibility.
Signature*
Date*

Month

Day

Year
Consent
I agree to the privacy policy.
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