Record Release Form Owner's NameLast Name(Required)First Name(Required)SpouseMailing AddressNumber / Street(Required)City(Required)State(Required)Zip(Required)Phone NumberCell(Required)AlternateOtherEmail(Required)Physical AddressSame as Mailing address Same as mailing address Number / Street(Required)City(Required)State(Required)Zip(Required)Are you changing primary veterinary care for your pet?(Required) Yes No If yes, why?(Required)Names of Pets for releaseDates of Treatment(Required)Select DatesLast YearLast 5 YearsAllFrom(Required) MM slash DD slash YYYY To(Required) MM slash DD slash YYYY Purpose of record releaseRecords to be released(Required) Vaccine Only Medical Medical with imaging/bloodwork Select AllI herby authorize Animal Medical Salado to release the selected records for the pets listed above. To the agents listed below. I understand that express permission to release records is required by the Texas State Board of Veterinary Medical Examiners. This release will expire in 1 year from the date of signature.Name(Required)Date(Required)Digital Signature(Required)Release ToName(Required)Phone Number(Required)Address(Required)Email(Required)NamePhone NumberAddressEmail
