• Owner's Name

  • Date Format: MM slash DD slash YYYY
  • Co-owner's Name & Contact #

  • Pet Information

  • Date Format: MM slash DD slash YYYY
  • By checking “yes” I hereby grant Chanticleer Veterinary Hospital permission to use any photographs taken of myself or my pet, in any and all business publications, including but not limited to website entries, social media, and marketing materials without payment or any other consideration. I understand and agree that these materials will become property of Chanticleer Veterinary Hospital and will not be returned and hereby authorize to edit, alter, copy, exhibit, publish or distribute all photos for purposes of publicizing programs or for any other lawful purpose. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby release rights to all claims, demands, and causes to action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of this authorization.
  • Date Format: MM slash DD slash YYYY