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

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Date