First Name* Last Name* Address City State Zip Code Primary Phone* Email* Best way to reach you? PhoneTextEmail Your Pet(s) Spouse/Co Owner Phone Your Pet(s) Name Breed Your Pet(s) Date of Birth Color Sex (Sprayed or neutered) Any chronic diseases/illnesses that we should know about * Is your pet(s) under medications? * How did you hear about us? * Family/FriendInternet SearchFacebookOther (Please indicate below) Is anyone in your home (human or pet) allergic to peanut butter or have any other allergies? * I, * the undersigned, am the owner or agent for the owner of the animal(s) described, and I have the full and exclusive authority to execute this consent. I certify that I am 18 years of age or older.I give permission to doctors, staff, authorized agents, or representatives of this hospital to examine, prescribe for, and treat my pets.I consent to video and audio recording for the purpose of enhancing the quality of care and ensuring the safety and well-being of both myself and the veterinary staff.I agree to pay for all services rendered and medications, goods, and supplies when purchased.I understand that all fees are due at the time services are rendered and the hospital accepts cash, check, and all major credit cards.I understand that a deposit may be required for surgical or medical treatment.I release this hospital from any and all liabilities. By my signature below, I hereby acknowledge that I agree to all of the above and acknowledge the receipt of a copy of this agreement upon request. * Owner/Agent Name Date