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Record Release Form
Full name
*
Street Address
*
City
*
State
*
ZIP Code
*
Phone
*
Email
*
Pet Name
*
Reason for request
*
Reason for request
A
Insurance Purposes
B
Second Opinion
C
Moving
D
Appt. with Specialist
E
Personal Files
F
Closer to Home
G
Unhappy with Care
H
Other
Please specify reason
*
Email address records to be sent to:
*
Specific date range needed (e.g. 1/1/2025 – 6/6/2025):
*
Date records are needed by:
*
Submit