Records Request/Release

"*" indicates required fields

MM slash DD slash YYYY
Current Owner's Name*
Current Owner's Address*
Select All Records to be Released*
Check all that apply
MM slash DD slash YYYY
Reason for Records Request*
Where should we send your records?

This information may be disclosed to and used by the following individual or organization:

By signing this, I authorize Charleston Equine Clinic to release and disclose the above stated medical records. I understand that if I wish to revoke this authorization I must do so in writing and the written revocation must be signed and dated with a date that is later than the date on this authorization.