Burnt Hills Veterinary Hospital
“The Best Of Care for The Best of Friends”
145 Goode Street
Burnt Hills, NY 12027
518-399-5213 Phone
518-399-3370 Fax
[email protected]
Veterinary Medical Records Release Form
I, the undersigned do hereby grant my permission for the
release of any or all of the information contained in the
medical record of the pet listed to be given upon
request:
Pet Name________________________________________
Pet Name________________________________________
Pet Name_________________________________________
Pet Name_________________________________________
Client Signature ________________________Date________
****This release will remain in effect until you notify us in
WRITING of any desired changes****