Medical Release

The following medical release form pertains to animals that have received prior services at West Valley Humane Society. Please be prepared to upload a photo of the animal and a photo of your drivers license or government issued ID.

Name(Required)

First Last

Addtional Owner Names

If there are additional owners associated with this animal, please provide their names.

First Name

Last Name

Phone(Required)

Please list your phone number.

Email(Required)

Please list your email.

Enter Email Confirm Email

What type of animal is this in reference to?

Dog

Cat

Other

Please upload a photo of the Animal(Required)

Accepted file types: jpeg, jpg, png, pdf, heic, Max. file size: 300 MB.

How would you like the records sent?(Required)

Fax

Email Medical Information Option(Required)

Provide the email address to where the records will be sent.

Enter Email Confirm Email

Fax Medical Information Option(Required)

Provide the fax number to where the records will be sent.

Reason For Request(Required)

Please specify the reason for your request so that we can include pertinent information.

Please upload a photo of your Drivers License or Government issued ID(Required)

Accepted file types: jpeg, jpg, png, pdf, heic, Max. file size: 1,000 MB.

Signature(Required)

I, the undersigned, do hereby grant my permission for the release of any or all medical information pertaining to the pets associated with the owner's name(s) provided in this form to the designated person or veterinary practice. Please sign below:

West Valley Humane Society: Caring for animals, promoting adoption, and supporting responsible pet ownership throughout the Nampa and Caldwell, Idaho area.

Medical Release

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