1 Start 2 Complete Owner's Full Name * Primary Phone * Alternate Phone Current Mailing Address * Animal's Name * Breed * Sex * M F Color * Age * I, being responsible for the described animal, have the authority to grant my consent to receive, prescribe and treat my pet. Further, I accept full financial responsibility for authorized medical treatments. I also authorize Advanced Animal Care to fax my animal's records to my regular veterinarian Signature Signer Name * Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20192020202120222023 AUTHORIZATION FOR RELEASE OF RECORDS Under Kentucky law, we must have a release signed by you before any information regarding your pets can be released to others. Please indicate below if you have anyone that you know will need information regarding vaccination history, pet's health status, etc. Please note if your pet is hospitalized only people listed in this form can call and check on the animal. PLEASE NOTE, only the OWNER and CO-OWNER is authorized to make decisions regarding the health care of your pet. Co-Owner(s) Dependent(s) Regular Vet Regular Groomer/Trainer I authorize * I AUTHORIZE Advanced Animal Care to use my pet(s) photo for social media or clinic use. ("Like" us on Facebook or "Follow" us on Twitter) I DO NOT AUTHORIZE Advanced Animal Care to use my pet(s) photo for social media or clinic use. Please verify all info above is true * I verified that all info above is true Signature Signer Name * Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20192020202120222023
