Briarwood Animal Clinic

1621 W 86th St
Indianapolis, IN 46260

(317)872-4326

briarwoodanimalclinic.com

Records Release Form

Name (required)
First Name (required)
Last Name (required)
Pet(s) Name (required)

Records Release Form for Non-Specified Location
I authorize Briarwood Animal Clinic to provide medical records to the following now or at any time in the future, in reference to the specific pet listed above. This may include vaccinations, medical history, or other information requested by the facility or person. I understand that Briarwood Animal Clinic and its staff will do their best to only release my pets medical records to reputable boarding/grooming/daycare facilities and may call me if they have any concerns. I also do not hold them liable for any information that is released.
By checking the box, you understand and authorize the release of records
Records Release For Specified Location
I authorize Briarwood Animal Clinic to provide medical records to the following now or at any time in the future, in reference to the specific pet listed above. This may include vaccinations, medical history, or other information requested by the facility or person:
Name of Facility

Phone:

Fax:

By checking the box, you understand and authorize the release of records

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