BridgeMill Animal Hospital

9560 Bells Ferry Road
Canton, GA 30114

(770)479-2200

bridgemillvet.com

Medical Records Release



Date: _____________________

Owner Name:________________________________________   Pet(s) Name(s):_____________________________________________


I authorize BridgeMill Animal Hospital to release medical records pertaining to the pet(s) named above, or any pet(s) that I register with BridgeMill Animal Hospital in the future, to a requesting veterinary hospital or other party by fax, surface mail or email. 


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                      Owner Signature

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                        Street Address

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                         City/State/Zip

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                          Telephone