"*" indicates required fields 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 American Veterinary Hospital to release the above listed pet’s veterinary medical records to:* I request and authorize American Veterinary Hospital to release the above listed pet’s veterinary medical records to: * Name of person or practice:* Email or Fax Number* Reason*I understand once records are released from American Veterinary Hospital the practice will:* I understand once records are released from American Veterinary Hospital the practice will: * - Make my pet’s file inactive - Suspended reminders - no future reminders will be sent - No longer approve or write prescriptions for this pet hereby certify that I am the owner or authorized agent of the above named pet(s) and release American Veterinary Hospital from any harm and responsibility from this date forward.* I hereby certify that I am the owner or authorized agent of the above named pet(s) and release American Veterinary Hospital from any harm and responsibility from this date forward. * Agent’s Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
