Consent for Treatment | Animal Medical Center of Mid-America

"*" indicates required fields

Date*

Your full name*

First Last

Best phone number to reach me today*

Patient's name*

Patient's species*

Patient's breed*

Patient's age*

Patient's sex*

Animal Medical Center of Mid-America maintains an online and public relations presence for purposes including marketing and client education (i.e. website, Facebook page, etc.) Part of this presence includes posting and sharing photographs of our practice and its daily workings. We may be interested in using images of your pet(s) and/or family as part of the effort to educate the public about our hospital and services. We would refer to pets and people pictured by first name only, if at all.

Signature*

By typing your name here and submitting you agree to the terms above.

Name

This field is for validation purposes and should be left unchanged.