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    *Must be at least 18 years of age to complete this form*
  • Client Authorization

  • I 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.
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  • Patient Information

  • Second Patient Information

  • Training / Boarding Information

  • Consent for Agent Authorization of Veterinary Services

  • I, (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.
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  • Photography Release

  • I 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.
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