Owner Name
Most Recent Vaccination Date

I am financially responsible for the patient described above and agree to pay all fees incurred. I understand that any medical or surgical procedure is attended by some risk and that it is not possible to guarantee the successful outcome of such procedure. I give my permission for Dunwoody Animal Medical Center to use my image, my pet’s image, and my pet’s name on all social media sites and the clinic’s website. This agreement is in force indefinitely from this date unless I notify the hospital in writing to the contrary.

Sign above