Authorization For Release Of Veterinary Medical Records
To:____________________________________________________________________DVM
_________________________________________ __________________________________
Address City/State/Zip
You are authorized to release to Pampered Parrots Avian Rescue, any and all medical records related to
Diagnosis, treatment and well visits that _______________________________ ___________________,
Name of pet Species
band/id# (if applicable)_____________________ may have received.
A photocopy or facsimile of this authorization shall have the same force and effect as the original.
All prior authorizations are cancelled.
___________________________________________________________
Print Name
___________________________________________________________ ____________________
Signature Dated
To:____________________________________________________________________DVM
_________________________________________ __________________________________
Address City/State/Zip
You are authorized to release to Pampered Parrots Avian Rescue, any and all medical records related to
Diagnosis, treatment and well visits that _______________________________ ___________________,
Name of pet Species
band/id# (if applicable)_____________________ may have received.
A photocopy or facsimile of this authorization shall have the same force and effect as the original.
All prior authorizations are cancelled.
___________________________________________________________
Print Name
___________________________________________________________ ____________________
Signature Dated
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