Date MM slash DD slash YYYY *Must be at least 18 years of age to complete this form* Owner Name* Driver’s License Number/State Spouse Driver’s License Number/State Mailing Address* Physical Address City* State* ZIP Code* Cell Phone Number*Residence Phone NumberPlace of Employment Work Phone NumberEmail Address How did you hear about Countryside Large Animal Vet? Whom can we thank for your visit? Client AuthorizationI hereby authorize Countryside Large Animal Veterinary Services, PLLC, their attending veterinarians and staff, to examine, prescribe for, and treat the animal owned or leased by me listed above. In the event that my animal requires euthanasia, and I cannot be reached for consent, I authorize the attending veterinarian to act on my behalf to end needless suffering, without fear of liability. I assume responsibility for all charges incurred in the care of my animals and will instruct the attending veterinarian if there are any financial or medical limitations to emergency care. Agent / Owner Signature*Date* MM slash DD slash YYYY Patient InformationName / Tag #* Nickname Species* Equine Bovine Caprine Ovine Porcine Camelid Age / Birthdate* Breed* Color* Sex:* Male Female Altered Male Altered Female Identifying Markings/Brands/Scars Second Patient InformationName / Tag # Nickname Species Equine Bovine Caprine Ovine Porcine Camelid Age / Birthdate Breed Color Sex: Male Female Altered Male Altered Female Identifying Markings/Brands/Scars Training / Boarding InformationTraining / Boarding Facility Name Facility Contact Name Phone NumberFacility Physical Address City State Zip Code Consent for Agent Authorization of Veterinary ServicesI, (the owner), in conjunction with the agreement between myself and (agent), for the boarding / training of my animal(s) understand that it may, from time to time be necessary that veterinary examination, treatment or consultation be provided. In the absence of specific written to the contrary, I hereby authorize the above named individual to act as my agent in the arrangement for such services with a licensed veterinarian. Further, I agree to be responsible for the payment of all fees incurred, this payment to be made directly to the hospital. Owner SignatureDate MM slash DD slash YYYY Photography ReleaseI hereby give permission to Countryside Large Animal Veterinary Services, PLLC, to publish photographs and videos taken of myself and/or the minor child or children listed below, as well as our animals and our names and likenesses, for use in Countryside’s print and online marketing materials (for example, Countryside’s Facebook page, website and newsletter). I understand that the images and videos may be used in print publications, online publications, presentations, website and social media. I also understand that no royalty, fee or other compensation shall be payable to me by reason of such use. Parent/Guardian’s SignatureAnimal’s Name PhoneThis field is for validation purposes and should be left unchanged.
