Medical Release Form

Owner Information

Name*

First Last

Home Phone

Cell Phone

Address*

Street Address Address Line 2 City State ZIP Code

Email

Pet Information

Number of Pets

Please enter a number from 1 to 7.

Please enter 1-7.

Pet #1 Name

Pet #1 Species

Cat
Dog

Pet #2 Name

Pet #2 Species

Cat
Dog

Pet #3 Name

Pet #3 Species

Cat
Dog

Pet #4 Name

Pet #4 Species

Cat
Dog

Pet #5 Name

Pet #5 Species

Cat
Dog

Pet #6 Name

Pet #6 Species

Cat
Dog

Pet #7 Name

Pet #7 Species

Cat
Dog

Previous Veterinarian Information

Name

Office Phone

Fax

Address

Street Address Address Line 2 City State ZIP Code

Email

Authorization

I authorize the release of all medical records (please include all doctors’ notes) of the pet(s) listed above to be sent to Advanced Animal Care.

Today's Date*

Signature of client responsible for pet:*

Owner of Authorized Agent

Printed Name*

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Owner Information

Pet Information

Previous Veterinarian Information

Authorization

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