Records Release Authorization

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 the veterinarians at Veterinary Wellness Center of Boerum Hill to release the requested medical information for my pet (s) to the requested person/company named above. 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 6 months 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.