West Linn - Authorization to Release Vaccination Records Pet Parent Information: Pet Parent Name * First Name Last Name Address * City * State * Zip Code * Phone Number * Dog Information Dog's Name * Breed * Dog's Name Breed Vet Office * Vet Phone Number * (###) ### #### PET PARENT SIGNATURE: * I hereby certify that I am the owner (Pet Parent) or authorized agent of the Pet Parent of the above-described pet(s). Further, I hereby request and authorize this veterinarian to release the requested medical information for my pet(s) to Safe and Hound LLC. I release the veterinarian and staff from any legal responsibility or liability for the release of information to the extent indicated as authorized herein. This authorization expires 90 days from the date of signature. I understand I may revoke this authorization, but the revocation may not be applied retroactively once the information specified herein has been released. Date * MM DD YYYY Thank you!
