EmailMe Form - Authorization to Release Vet Records to J&L

Owner/Client's Name

First Last

Email

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Vet Info

Name of Vet's Office

Vet's Address

Vet's Phone number

Vet's Fax number

Email address of Vet office

Pet Info

Pet's name

Date of birth (if known)

Breed

Other details

I hereby certify that I am the owner or authorized agent of the owner of the above described pet(s). Further, I hereby request and authorize said clinic to release the
requested medical information for my pet(s) to
J&L. *

Yes

Owner's name *

Signature *

Clear

To add a signature on the "Signature" field, simply do a left-click on your mouse to start writing. Click on the "Clear" link if you need to re-write the signature. Please refer to this screencast for a visual reference: https://www.screencast.com/t/wPlRgVeL

Date Time *

MM / DD / YYYY