"*" indicates required fields

"*" In accordance with regulatory provisions of Wisconsin State Statute 453.075 and the Veterinary Practice Act
regarding the confidentiality of patient medical records, a written authorization or waiver is required
for us to provide a copy of your pet's medical records.

Owner’s Information


Pet’s Information

I request and authorize Star Veterinary Center to release the above listed pet's medical records to:*
I hereby certify that I am the owner or authorized agent of the above named pet.*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.