Record Release Authorization Form

Owner Name(Required)

Date(Required)

Select an option(Required)

All pets

Specific pet(s)

Client's Phone Number(Required)

Which Specific Pets?

How would you like to release your pet records?(Required)

I authorize Appanasha Pet clinic to release my pets records to any requesting clinic, emergency facility, boarding or grooming facility, rescue, or shelter.

I do NOT authorize release of my pet’s records.

I prefer a phone call or correspondence at the time of request to release records.

Signature(Required)

This form is valid for one year from date of signature. If you choose all pets, the form will be linked to all active pets on your account. If you choose to mark a specific pet (s), the record release will only be linked specifically to that preferred pet (s). If you have any questions, please call Appanasha Pet Clinic at 920-725-8307.

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