"*" indicates required fields "*" In accordance with regulatory provisions of Wisconsin State Statute 453.075 and the Veterinary Practice Act regarding the confidentiality of patient medical records, a written authorization or waiver is required for us to provide a copy of your pet's medical records.Owner’s InformationName* First Last Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pet’s InformationPet's Name* Species* Cat Dog SexMaleNeutered MaleFemaleSpayed FemaleBreed* Date of Birth / Age* I request and authorize Star Veterinary Center to release the above listed pet's medical records to:* I request and authorize Star Veterinary Center to release the above listed pet's medical records to: Name of person or practice:* Email or Fax Number* Reason*I hereby certify that I am the owner or authorized agent of the above named pet.* I hereby certify that I am the owner or authorized agent of the above named pet. Agent’s Signature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
