Vaccine and / or Micro-chipping Authorization

Vaccine and / or Micro-chipping Authorization

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Client's Name*

First NameMiddle Initial Last Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Mobile Number*

Area CodePhone Number
Phone Number

Area CodePhone Number
Work Number

Area CodePhone Number
Company
Date of Appointment*

MonthDayYear
Date
Animal's Name (s) (please list all animals being seen on the appointment date indicated above) *
Micro-chipping is mandatory for all packages, unless the pet is previously micro-chipped.I hereby authorize the implantation of a microchip into the animal described above. The procedure has been explained to me fully and I understand it completely and have no questions or reservations. Furthermore, I agree to register my microchips with the manufacture, within ten days, and understand registration is free. I further understand, that if I do not register the microchip, I can be subject to a $25 fee, per microchip, for failing to do so. A brochure with registration info will be sent home with me today. Additionally, if the animal is re-homed I agree to ensure to have the new owner/care provider register the microchip into their name. I understand if I fail to do this I may be held responsible if the animal is found abandoned, etc. (Initial)*
In granting this consent to vaccinate, I hereby state that:I understand that the animal(s) listed above may be exposed to disease.I understand that the vaccination of the animal(s) listed above, may, with the given vaccine will substantially reduce, but may not completely eliminate his/her chances of contracting these disease (s).I understand that the animal(s) listed above may develop side effects. I understand these side effects are usually minor and pass without the need for additional veterinary care. I understand that should the animal(s) listed above, develop any severe or unanticipated reaction to the vaccination, I should contact this clinic, or my local veterinary emergency clinic immediately for instructions.I understand that the animal(s) listed above may have slim chance of developing a fibrosarcoma-type tumor at the vaccination site. I understand that this type of tumor, should it occur, is life-threatening and may require extensive medical or surgical treatment.I have had an opportunity to ask any questions I have concerning this vaccination. All such questions have been answered to my satisfaction. (Initial)*
Additional Comments
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Today's Date*

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