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Client Consent Form
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Owner Name
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First
Last
E-mail
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Phone
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Patient Name
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Today's Date
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The owner/agent ("owner") of the above described animal or animals hereby consents and authorizes Sport Dog Specialty Medicine, LLC, Dr. Love and her employees to prescribe for, treat and operate upon the above described animal. It is understood by the owner that with any procedure performed, some degree of risk is inevitable, and it is not possible for Sport Dog Specialty Medicine, LLC, it's staff or employees to guarantee a successful outcome of any medical, anesthetic or surgical procedure. The owner understands that reasonable precautions will be taken to prevent injury, escape or death of the above described animal while he or she is in the care of the Sport Dog Specialty Medicine, LLC, Dr. Love and/or her employees. It is understood that injury, escape or death are not always avoidable and that the owner will not hold Sport Dog Specialty Medicine, LLC, Dr. Love or her employees responsible for the injury, escape or death of the above described animal while it is in the care of the Sport Dog Specialty Medicine, LLC, Dr. Love or her employees. The owner/agent also understands and agrees that if the animal should remain with the Clinic for a period in excess of ten (10) days without prior arrangements being made between the Clinic and the owner, the Clinic, after two (2) unsuccessful attempts to contact the owner at the address or telephone number given above, may in any manner dispose of the animal at its discretion. The owner acknowledges, accepts and assumes full and total financial responsibility for any and all services rendered by Sport Dog Specialty Medicine, LLC, Dr. Love or employees in the treatment of the above described animal or animals, and to pay for such services when the services are performed or when the animal is picked up from the care of Sport Dog Specialty Medicine, LLC and Dr. Love. Payment is due at the time services are rendered. If for some reason any payment is not made at the time services are rendered or within 10 days thereafter, the account may be referred to a collection agency and any collection charges and attorney’s fees are the responsibility of the owner.
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I have read and understand.
PHOTO RELEASE AUTHORIZATION - I hereby give Sport Dog Specialty Medicine, LLC and Dr. Love and its representatives the right to take photographs and/or videos of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Sport Dog Specialty Medicine, LLC and Dr. Love may use such photographs and videos of me and/or my pet with or without my name and for any lawful purpose, including educational, publicity, illustration, advertising and web content.
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I have read and understand.
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