Online FormMedical Release Form

Allow us to release your pet’s medical information to another provider by completing our convenient online form.

Medical Release Form

Please fill out this form as completely and accurately as possible so we can most easily complete the release process.

OR

You may use the PDF version by clicking the DOWNLOAD FORM button and then completing the printed form by hand. Please bring the completed PDF form with you for your pet’s first appointment.

DOWNLOAD FORM

Name *

First

Last

E-mail *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Your previous or alternate veterinarian(s):

By signing below, I hereby authorize the immediate transfer/sharing of all medical records pertaining to my pet named with Abel Pet Clinic, Inc., including vaccinations, results of examinations, diagnostic or screening tests, and medications prescribed. These may be sent by fax to: (916) 684-6854, by email at info@abelpethospital.com or if time permits, by mail to: 9098 Laguna Main St #1 Elk Grove CA 95758. *

I understand and agree to the above statement

Please also transmit records pertaining to my other living pet(s) *

Yes
No

I authorize Abel Pet Clinic, Inc. to transmit future records regarding my pet(s) at the request. *

I understand and agree to the above statement

Other name(s) on record:

Signature *

Clear Signature

Print Name *

Date *

Comment

Online FormMedical Release Form

Medical Release Form

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