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Record Release Form

Marked Fields Are Required [*]

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Pet Name*
Reason for request*
- Insurance Purposes
- Second Opinion
- Moving
- Appt. with Specialist
- Personal Files
- Closer to Home
- Unhappy with Care
- Other
Please specify reason*
Email address records to be sent to:*

Add additional recipients in a separate line.
Specific date range needed (e.g. 1/1/2025 – 6/6/2025):*

Add additional recipients in a separate line.
Date records are needed by:*
MM slash DD slash YYYY
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Email
This field is for validation purposes and should be left unchanged.

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