NameThis field is for validation purposes and should be left unchanged.Owner/Agent*I certify that I am authorized to release records and I give permission for the following records to be released for the horse named*Please release the following records (check all that apply) Vaccine Record Laboratory Reports Imaging (Radiographs &/or Ultrasound images) Entire Medical Record (all the above) Other Records are restricted to this date range Other RecordsRestricted Date RangePlease release these records to:Name*Contact: (phone or email)*Additional comments, requests, or restrictions:*Full Name as Signature*Please enter your full name in the field above. By doing so, you acknowledge that this serves as your digital signature.Date* MM slash DD slash YYYY
