Medical Records Release Form

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Medical Records Release Form

Online Submission for Records

Forms must be completely filled out online only and 24 hours' notice must be given to process your records. The office is open Monday - Friday. Requests submitted over the weekend will take over 24 hours to process.

Today's Date

Animal's Name

Breed

Age

Address

Address 2

City/Town

State/Province

Zip/Postal Code

Owner's Telephone

Please EMAIL my Records to the Following Address:

Second Telephone (optional)

First Name

Last Name

Comments

I would like to receive e-news (optional)

How did you hear about us?

By signing below, I certify that I am the owner of the animal listed above and hereby request a copy of my animal's veterinary records to be made available via the e-mail I provided.

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Medical Records Release Form

Online Submission for Records

peggy adams animal rescue league Tax ID #59-0637811

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