Skip to Content

Authorization to Release Veterinary Records

Records to be released are to be faxed or emailed to the stated recipient requested below as soon as possible:

Pet Parent Information:
Pet Information

Please include copies of (circle):  Vaccination Records  Laboratory Reports  Exam  Reports  Surgery Reports  Pathology  Biopsy  Reports  Radiology  X-Ray Reports  Entire Medical Record

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 San Dimas Pet Clinic. 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.

Sign above
Back to top