Your Name *

First Name

Last Name

Consent *

By submitting this form, I, the owner of the animal described above, agree to the following: I understand that my pet may be photographed at Van Stavern Small Animal Hospital (VSSAH) or that images I share with VSSAH may be used in promoting services, either in print or on the internet. I also understand the information above may be used in part or in full or in a modified form for these same promotions. With my signature below I grant permission for my pet to be photographed, or his/her images recorded, for any legal use including but not limited to: publicity, advertising, and web content. I also grant permission to use the information on this form for the same purposes. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses. I agree that this form will remain in effect until revoked at the discretion of VSSAH or by my written request. I understand that there will be no royalty, fee, or other compensation payable to me for my or my pet's participation in this release.

I Acknowledge & Agree