Cornell University Hospital for Animals

 

For Clients


Authorization for Release of Patient/Medical Records

All fields with bold blue labels must be filled in.

I, the undersigned, owner or authorized agent for the owner, of the above described animal, authorize Cornell University Hospital for Animals to copy medical information pertaining to the above-named animals' medical record.

Owner Signature, Date
Authorized Agent Signature, Date
Authority to Sign, Date
Check all that apply:
 
 
Information to be provided to:


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