POTBELLIED PIG MEDICAL RELEASE AUTHORIZATION FORM

I HEREBY AUTHORIZE COPIES OF ANY AND ALL MEDICAL RECORDS INCLUDING DIAGNOSTIC LAB AND X-RAY RESULTS TO BE FURNISHED TO THE DUCHESS FUND™ FOR MEDICAL EDUCATION TO BE PUBLISHED ANONYMOUSLY.

(A copy of this shall be as valid as the original)

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PRINT NAME

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ADDRESS

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CITY, STATE, ZIP

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PHONE                                  EMAIL

THE DUCHESS FUND™
M214 Sugarbush Lane
Marshfield, Wisconsin, WI 54449
PH: 715-383-0133
EMAIL: [email protected]
 

THE DUCHESS FUND IS A CHARITABLE PROJECT TO ENLARGE THE AMOUNT AND ENHANCE THE QUALITY OF DATA AVAILABLE TO THE INDIVIDUAL PRACTITIONER RELATIVE TO THE CARE AND NEEDS OF POTBELLIED PIGS AS LONG TERM COMPANION ANIMALS.

FOR MORE INFORMATION GO TO www.duchessfund.org
CALL 715 383 0133
EMAIL: [email protected]

THANK YOU FOR YOUR SUPPORT!!!!