RELEASE OF INFORMATION
AUTHORIZATION FOR RELEASE OF INFORMATION

HOPE BEFORE HEAVEN INC.
P.O. BOX 2002
NEW MARKET STATION
NIAGARA FALLS, NY 14301

PHONE: 716-236-7346                          FAX; 716-236-7137

EMAIL: hopebeforeheaven@ymail.com               WEB: hopebeforeheaven.com


AUTHORIZATION FOR RELEASE OF INFORMATION


I,_____________________.  Give full authorization to Dr.________________________

To furnish information regarding my pet (pets name) _______________________.

To: HOPE BEFORE HEAVEN INC.

For the purpose of evaluation for monetary help for the emergency care of the above
named pet. By signing and dating this release of information I allow the doctor listed
above to share specific information regarding my pet’s health and treatment to be
performed.  This consent remains enforce for 365 days from date of signature but can
be revoked at any time by the undersigned.

I also agree to the use of my pet’s photo and medical information on Hope Before
Heaven’s website without compensation.


OWNERS NAME___________________________________________

ADDRESS_________________________________________________

CITY/STATE/ZIP__________________________________________

PHONE#______________________EMAIL______________________

OWNERS SIGNATURE_____________________________DATE__/__/__