Appointment Booking & Authorisation Form

Owners Prefix*

Owners Gender*

FemaleMaleOther

Owners Name (as per current DACO registration if applicable)*

First NameLast Name

DACO Breeder Number (if applicable)

Owners Date of Birth*

Date

Owners Main Phone Number*

Second Phone Number (Home or Work)

Please enter a valid phone number.

Owners Email (as per current DACO registration if applicable)*

example@example.com

Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owners Postal Address (if different from above)

CityState / Province

Postal / Zip Code

Alternative Contact

First NameLast Name

Alternative Contact Phone Number

Please enter a valid phone number.

Which service type are you booking?*

MicrochippingPregnancy Ultrasound

If booking an Ultrasound, please enter up to three (3) breeding or suspected breeding dates

Date

Please complete ALL COLUMNS for each animal to be microchipped: (a non-refundable deposit will be required if booking more than 3 animals or you are located out of the Murraylands area.)*

	Animal Type	Name	Dogs Only - DACO Rego Disc # (if registered)	Date of Birth (approximate if unknow) DD/MM/YYYY	Sex	Breed(ie. Domestic Shorthair, RagDoll)	Primary Colour(s)	Distinguishing Features
Animal 1
Animal 2
Animal 3
Animal 4
Animal 5
Animal 6
Animal 7
Animal 8
Animal 9
Animal 10

Does the animal(s) have any health issues? Please list:*

Does the animal(s) have any behavioural concerns? If yes, please describe:*

Appointment*

Please list a range of suitable dates and times for your appointment:*

If your preferred time/day is not avaiable or your appointment is urgent, please give me a call on 0411 461 624

What is the physical address where you would like the appointment?*

In my own home at the street address listed aboveOther

How will you be finalising payment (at time of the appointment)?*

Do you consent to having your animal(s) and you photographed for advertising purposes which may include on social media?*

YesNo thanks

How did you find out about this service?*

General

I acknowledge that I am over 18 and the legal owner of the animal(s) listed above.
I understand, have read, and completed this form truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.
I understand that withholding information or providing misinformation may result in accident, illness or injurty that will be at my expense.
I give consent for a microchip to be implanted into the above animal(s) and/or a pregnancy ultrasound procedure to be perfomred on the above animal(s).
I understand payment is due to be finalised at the time of the appointment (either full payment of total or less deposit if applicable). Payment can be made by credit card (surcharge may apply), OSKO bank transfer, PayID or cash.
If I am booking in 3 (three) or more animals or I am located outside of the Murraylands area, I may be required to pay a non-refundable deposit of $10 per animal prior to the appointment being accepted by AMC Microchipping.
I acknowledge that I may need to assist in safely restraining/distacting the animal(s) if required by the technician and will follow their direction at all times.
I acknowledge that the technician holds the right to terminate the session or not implant or ultrasound any animal at any time at the technician's discresion and safety for the animal(s).
I understand for both microchip implant and pregnancy ultrasound procedures, that if the technican notes anything of variablity from the normal, I will be required to seek veterinary assistance for further investigation and diagnosis.
I release the technician from any and all liability associated with any injuries/current and future conditions resulting from the microchip being implanted into the above animal(s) and/or ultrasound being conducted and assume full responsibility thereof.

Microchipping

I acknowledge that I will be required by law to complete the transfer of the animal(s) into my name on Dogs and Cats Online (DACO) and I may be required to set up an account if I don't already have any registered animals.
I acknowledge that the animal(s) is/are over 6 weeks of age.
I understand that the insertion of a microchip implant is considered a veterinary procedure, small amounts of blood may be visible during the procedure. I will monitor the implant site and handle with care for not less than 14 days and not bathe or swim the animal within 48 hours of the implant.
I acknowledge that implants may move around the body during the animal(s) lifetime and or rarely may fail to read and may need to be replaced (get your animals microchip read at every veterinary appointment to ensure it's reading correctly).
I will seek veterinary attention should the implant site become hot, red, weeping or my animal appears unwell after the procedure.

Ultrasounds

I understand that an ultrasound provides an indication only and is not able to provide exact dates for birth expecancy nor the number of actual kittens/puppies viable at delivery.
I understand that there is no guarantee any pregnancy detected will go full term and be viable at birth.

Date*

Date

Name*

First NameLast Name

Signature*

Appointment Request & Authorisation Form

Animal Information

Authorization