I hereby authorize Lake Pine Animal Hospital to examine, prescribe for, or treat the pet described above. I agree to pay for services rendered at the time they are performed. I authorize Lake Pine Animal Hospital and/or representatives of Lake Pine Animal Hospital to contact me regarding this account via the information provided above. If I am unable to attend my scheduled appointment, then I authorize the agent I send in my stead to make medical and financial decisions on my behalf. Methods of payment are limited to cash, check, Visa, Mastercard, or Care Credit. I certify that I have read and understand this consent form Signature of Responsible Agent:*
Social Media Release: I grant Lake Pine Animal Hospital, it’s representatives, and employees the right to take photographs of me and/or my pet and that Lake Pine Animal Hospital may use such photographs without my name for such purposes such as publicity, social media, illustration and web content.*
