Authorization to Release Veterinary Records-Bayshorevet

Authorization to Release Veterinary Records

First Name

Last Name

Address

Phone Number

Please list the name, species, breed, and description of all pets for which you would like records released:

The information to be released includes:

Entire Medical Record

Vaccination History Only

Current Vaccinations Status Only

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 Bayshore Veterinary Hospital, to release the requested medical information for my pet(s) to the following veterinary clinic(s) and/or boarding/grooming facilities:

List record destination(s) name(s) and fax or email for forwarding:

I release Bayshore Veterinary Hospital and their veterinarians and staff from any and all legal liability for the release of information to the extent indicated and authorized herein. I may revoke this authorization in writing at any time.

Your Signature

Date