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CAREERS | Client Login

Hours 7161 Beth-Bath Pike (Route 512)
Bath, PA 18014

Veterinary Medical Release Form

Pet Information

Pet Name:*

Species*

Breed*

Description*

Pet Name:*

Species*

Breed*

Description*

Pet Name:*

Species*

Breed*

Description*

Pet Name:*

Species*

Breed*

Description*

Reason for Request:*

The information to be released includes:*

Entire Medical Record

Vaccine History Only

Last 12 Months of Records Only

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 Lehigh Valley Animal Hospital Bath, to release the requested medical information for my pet(s) to the following Veterinary Clinic(s) and/or boarding grooming facilities.

Entering your name below serves as a signature acknowledging the above-mentioned statement.*

Today's Date:*

Please provide my pets records to the following:*

I will pick up in person on - enter date: (Please allow 72 hours for request)
Please email to me at - enter email:
Please email to Veterinarian at - enter email:
Please mail to Veterinarian at - enter mailing address:

Lehigh Valley Animal Hospital