The required sections have a red * asterisk.
*Full Name:
*Street Address:
*City, State, Zip:
*Pet(s) Names:
I grant to Pinellas Animal Hospital, its representatives and employees the right to take photographs and recordings of any/all of my pet(s) on record with Pinellas Animal Hospital, in connection with the above-identified subject. I authorize Pinellas Animal Hospital, its assigns and transferees to copyright, use and publish the same in print and/or electronically.
I agree that Pinellas Animal Hospital may use such photographs or video of my pet(s) with or without their name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and Web content.
I release Pinellas Animal Hospital from any expectation of confidentiality and attest that I am the legal owner of the pet(s) on record and that I have the authority to authorize Pinellas Animal Hospital to use their photographs.
I have read and understand the above.
*Electronic Signature:
