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.