Longenbaugh Veterinary Hospital P.C.

15703 Longenbaugh, Ste. F
Houston, TX 77095

(281)856-7023

longenbaughvet.com

Your pet's medical records, even just the vaccination history cannot be given to anyone without your consent.

You can print out this form and fax it to us at 281-856-8651 or you can submit the form to us. Your submitted form will serve as a signed form.  Only an owner or co-owner can authorize release of records.  We must have these names on your records prior to the submission of this form. On the form below, please fill in your pet's name and a yes or no in the boxes below each category.  If you have multiple pets, you may put your last name followed by the word pets in the name box.



I give my permission to Longenbaugh Veterinary Hospital to release the medical records for my pet
Pet's Name

to the following
veterinarians
groomers
specified individuals

I understand that this submitted form will serve as my signature as the owner of this pet.
*Signature for forms not submitted
*Date
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