MEDICAL RECORD RELEASE

In order to release Medical Records from PenMar Equine to a separate party, please fill out the following form:

Owners Name

First Name

Last Name

Email

Horse's Name

Please release the records for the above listed horse to:

Persons Full Name/Email if known:

Select all that apply:

Medical Records

Radiographs

Ultrasound Images

Gastroscopy Results

Pre-Purchase Exam Findings

Bloodwork Results

I authorize PenMar Equine to release the above medical Records to the parties listed above.

Type your Full Name