Date*
Name*
First:
Last:
I request that Animal Health Clinic of Funkstown release my pet's medical records for the following pet(s):*
Be released to (name)*
Address*
Street Address:
Address Line 2:
City:
State/Province/Region:
ZIP/Postal Code:
26 East Baltimore Street PO Box 669 Funkstown, MD 21734 301-733-7579 ahcf@funkstownvet.com
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