Release of Records Authorization | Hebron Animal Hospital

Owner's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Please List The Pets You Wish For Us To Send Records For:

Pet's Name(Required)

Pet's Breed(Required)

Pet's Age

Pet's Sex(Required)

Female

Male

Pet's Name 2(Required)

Pet's Breed 2(Required)

Pet's Age 2

Pet's Sex 2

Female

Male

The information to be released includes:

Reason for release of records

If changing veterinarians, who is the new vet:

Fax or email where we are sending records:

Reason for changing:

**By signing this form, I am also authorizing Hebron Animal Hospital to obtain any records for the above mentioned animal/s from any previous Veterinarian, Shelter, Rescue or other facility. 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 Hebron Animal Hospital to release the requested medical information for my pet/s to the above-named facility(s). I release the Hebron Animal Hospital, 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. The Hebron Animal Hospital policy is to provide the requested release within two (2) business days of the written request.

Signature(Required)

Date(Required)

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