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Record Release Form

Disclaimer

PAYMENT IS REQUIRED IN FULL AT THE TIME SERVICES ARE RENDERED. ACCEPTABLE FORMS OF PAYMENT ARE CASH, AMEX, VISA, MASTERCARD, DISCOVER, CARECREDIT, AND SCRATCHPAY (CHECKS WILL NOT BE ACCEPTED).

Full name

*

Street Address

*

Street Address Line 2

City

*

State

*

ZIP Code

*

Phone

*

Email

*

Pet's 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

Email address records to be sent to:

*

Any additional recipients here:

Specific date range needed (e.g. 1/1/2025 – 6/6/2025):

*

Date records are needed by:

*