Client Name *

First Name

Last Name

Phone

(###)

###

####

Client Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is your horse microchipped? *

Yes

No

Records to be Released Include *

Please select all that apply

Diagnostics

Exams

Vaccination Records

All Records on File

Check all that apply:

Please fax records to (info below)

Please mail records to (info below)

Please e-mail records to (info below)

Please transfer all records to new owner (info below)

Recipient Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I hereby authorize and provide my written consent to this transfer of medical information. I understand that by authorizing Tumalo Ridge Veterinary Services, LLC and Tyler Newton, DVM to use/disclose the information, that they may receive compensation for reasonable expenses incurred for making photo copies of medical records. I understand that I may revoke this authorization in writing at any time by contacting Tumalo Ridge Equine Veterinary Services, LLC and Tyler Newton, DVM except to the extent that action has been taken in reliance on this authorization. This authorization expires (insert applicable date or event), on or within (6) months or the date of the authorization, whichever is greater. *

Printed Name of Owner or Authorized Agent

First Name

Last Name

Expire Date *

MM

DD

YYYY

Today's Date *

MM

DD

YYYY

*

I agree to electronically sign this document by typing my name.