"*" indicates required fields Step 1 of 2 50% SignatureDate MM slash DD slash YYYY Owner's Name Spouse / Other Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home TelephoneWork TelephoneCellular TelephoneEmail Place of Employment Driver's License Number State Emergency Contact Name Emergency Phone Number Pet's Name Age Date of Birth MM slash DD slash YYYY Species Dog Cat Other Gender Male Female Altered Yes No Breed Color Is your dog on Heartworm Prevention? Yes No Has your cat been tested for Leukemia and FIV? Yes No Is your pet Microchipped? Yes No Is your pet current on Vaccinations? Yes No Reason for visitHow did you first hear of us - Friend or individual we may thank List the names and ages of any other animals that you ownNameAges Add Remove I assume the responsibility for all charges incurred in the care and treatment of my animal(s). I also understand that these charges will be paid at the time of release and a deposit may be required for treatment. In the event, any account is not paid when due, the prevailing party shall be entitled to recover its reasonable attorney fees and any court costs, including costs of appeal or another review. In the event that your account is placed for collection with a collection agency, you agree to pay any collection fees that may be assessed in addition to the amounts owing. Signature of owner or responsible party Photo Release Form Permission to Use Photograph I grant to Family Pet Heath Care, its representatives and employees the right to take photographs of me, my pet(s) and my property in connection with the above identified subject. I authorize Family Pet Health Care, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Family Pet Health Care may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I have read and understand the above* Printed nameSignature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.