| I need to: | Authorize release of medical records to a third party |
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| Your Name | Kerri Edelen |
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| Pet(s) Name | Skye and Yogi |
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| Email | mamae4281@sbcglobal.net |
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| Address we have on file for you (for verification purposes). | 3018 Taylor Dr. Clarksville In |
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| Please Send: | Full medical history |
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| I am authorizing this records release: | Permanently/as needed in the future (i.e., insurance companies) |
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| Reason for Request: | Not a convenient place for me to bring my pets |
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| Name of office or person to send records to: | Care Pets Animal Hospital Sellersburg In |
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| Email Address to Send Records to: | records@carepetsah.com |
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| Signature |  |
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