I hereby authorize Seville Veterinary Hospital to examine, prescribe for, or treat the above-­‐described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid IN FULL at the time of services and that prepayment may be required for surgical treatment or hospitalization. I understand that Seville Veterinary Hospital requires photo identification and a $30 fee will be applied for returned checks.

I hereby consent and authorize the staff of Seville Veterinary Hospital to take photographs or motion pictures of me or my pet. I authorize Seville Veterinary Hospital to use, reuse, copy, publish , display, exhibit, reproduce these materials in any educational or promotional materials or other forms of media, which may include, but are not limited to publications, articles, brochures, websites, publications, electronic or otherwise, without notifying me.