Owner’s Information

Name*
Address*

Pet’s Information

Species*
I request and authorize American Veterinary Hospital to release the above listed pet’s veterinary medical records to:*
I understand once records are released from American Veterinary Hospital the practice will:*
  • - Make my pet’s file inactive
  • - Suspended reminders - no future reminders will be sent
  • - No longer approve or write prescriptions for this pet
hereby certify that I am the owner or authorized agent of the above named pet(s) and release American Veterinary Hospital from any harm and responsibility from this date forward.*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.