Please fill out all required fields. The info will be emailed to your veterinarian for their signature and your pet’s records. You will also receive a copy of this email for your records which you can print and bring to your veterinarian in the event they do not have an email.

Pet Parent Information:

Pet Information:

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 Dogwood Cottage. 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.

PET PARENT SIGNATURE:

**By entering your name in this field you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By entering your name you consent to be legally bound by this Agreement's terms and conditions.

Date:

This form will be emailed to your veterinarian to complete and send back to dogwood cottage. You will also receive a copy of that email.