Owner Name(Required)
Co-Owner Name
Pet Type(Required)

Sex(Required)
Previous Records Available?(Required)
Please list contact information for previous records & indicate if listing multiple pets
Add a second pet?
2nd Pet Type

Sex
Add a third pet?
3rd Pet Type

Sex
Physical Address(Required)
Mailing Address
How did you hear about our clinic?
I am the owner of the animal or am responsible for it and have the authorization to execute this consent. I hereby authorize the treatment of this animal and performance of such medical, surgical, or therapeutic procedures you determine to be indicated and use of such anesthetics as you deem advisable. I understand that all professional fees are due at the time of service. It is agreed that past due accounts are subject to maximum allowed per month late charges, and in addition, all costs of collection including a reasonable attorney's fee.
I grant permission to use any photographs taken of myself or my pet, in any and all of its publications, including website and social media entries, without payment or any other consideration. I hereby authorize to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing your programs or for any other lawful purpose. In addition, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby release rights to all claims, demands, and causes to action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of this authorization. In signing this consent, I give authorization to use my name and my pet’s name and information as printed below.