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HOME
About
Services & Times
Wilsonville Services
West Linn Services
Rates
Wilsonville Rates
West Linn Rates
Contact
Wilsonville Forms
Wilsonville Forms
Reservations
Intake Form
Vaccination Records
Daycare Agreement
Safe & Hound Rules
Printable Forms
West Linn Forms
West Linn Forms
Reservations
Intake Form
Safe & Hound Rules
Daycare Agreement
Vaccination Records
Grooming Intake Form
Printable Forms
West Linn - Authorization to Release Vaccination Records
Pet Parent Information:
Pet Parent Name
*
First Name
Last Name
Address
*
City
*
State
*
Zip Code
*
Phone Number
*
Dog Information
Dog's Name
*
Breed
*
Dog's Name
Breed
Vet Office
*
Vet Phone Number
*
(###)
###
####
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
*
MM
DD
YYYY
Thank you!