Authorization to Release Vaccination Records

Pet Parent Information:

Pet Parent Name *

Pet Parent Name

First Name

Last Name

Address *

City *

State *

Zip Code *

Phone Number *

Pet Information:

Pet Name *

Breed *

Pet Name

Breed

Vet Office *

Vet Phone Number *

Vet Phone Number

(###)

###

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PET PARENT SIGNATURE: *

I hereby certify that I am the owner (Pet Parent) or authorized agent of the Pet Parent of the above-described pet(s). Further, I hereby request and authorize this veterinarian to release the requested medical information for my pet(s) to Safe and Hound LLC. I release the veterinarian and staff from any legal responsibility or liability for the release of information to the extent indicated as authorized herein. This authorization expires 90 days from the date of signature. I understand I may revoke this authorization, but the revocation may not be applied retroactively once the information specified herein has been released.

Date *

Date

MM

DD

YYYY