I, the undersigned, am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. I agree to assume full responsibility for all charges incurred as a result of examinations, diagnostic tests, medications, treatments, surgical procedures or other veterinary services provided through the Animal Medical Center of Mid-America. My signature below certifies that I am over eighteen years of age.
I understand that all reasonable precautions will be taken against injury or escape of the animal, but the Animal Medical Center of Mid-America or its agents will not be liable or responsible to any person under any circumstances for or on account of the care, necessary surgical procedures/treatment or safe keeping of the animal, and I assume all risk with respect to the treatment and care of the animal.
I understand the Animal Medical Center of Mid-America encourages all owners to have their pets microchipped for identification purposes, and that it is the Humane Society of Missouri's policy to scan pets for the presence of a microchip at the time they present for veterinary services. If it is determined that an animal is not owned by or registered to another individual, I authorize the Humane Society of Missouri to contact this person as soon as possible to provide them with information it has concerning the animal.
I authorize the Animal Medical Center of Mid-America to release information regarding my pet's vaccination history upon request from pet grooming and boarding establishments as well from law enforcement agencies.
My questions have been answered, and I have read and fully understand this form and authorize treatment for my pet(s).