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Request to Release Information

The records of your pet(s) are considered confidential information. In order for us to release the information contained in these records to a third party, we are required to obtain written consent from you, the owner of the pet.

REQUIRED FIELDS [*]

Entering your full name will become your digital signature: [*]

Enter your pet's name: [*]

Name of person/clinic to release information to: [*]

Enter your email: [*]

Today's date: