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                                     AUTHORIZATION FOR RELEASE OF INFORMATION                           Back

VETERINARY CARE

I hereby grant permission for the release of the following information 

q  Medical history and General care

q  Health of my animal 

to an authorized representative of PETPALS, Inc. 

I understand that this information is confidential and that PETPALS, Inc. will not release any information obtained to any PETPALS, Inc. staff who is not authorized to review it or to anyone who is not affiliated with PETPALS, Inc.   

I understand that this information is to be used by PETPALS, Inc. to determine approval of my adoption application, general health status of my animal(s), and/or follow-up checks on my adopted animal(s). 

VETERINARIAN OFFICES USED:

___________________________________________________

___________________________________________________

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NOTE:  Do not sign this form unless the name of the veterinary office has been filled in.

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SIGNATURE                                                           DATE

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                    PRINT NAME                                      PHONE NUMBER