Lexington Dog Walk - Veterinary Medical Records Release Form
Client Name
I do hereby grant my permission for the release of any or all of the information contained in the medical record of those pets listed below to the following person or Veterinary practice:
Pet Name 1 for Release of Medical Records
Pet Name 2 for Release of Medical Records
Pet Name 3 for Release of Medical Records
Pet Name 4 for Release of Medical Records
Release Records to:
Lexington Dog Walk, LLC
Email to:
tabitha@lexingtondogwalk.com
Reason for Request of Records:
Lexington Dog Walk requested paperwork.
Date
Electronic Signature
By typing my name below and submitting this form electronically, I acknowledge and agree that my typed name constitutes a legally binding signature and
I am accepting this document as a contractual agreement.
Owner's Name
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