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Primary Owners Name (required)
Secondary Owner's Name
Pet's Name (required)
Pet's Date of Birth or Age (required)
By checking the "Owner's Authorization" box below I hereby authorize the veterinarian(s) at Veterinaire Pet Care to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal and understand that my balance is due at the time of release. I further acknowledge that a deposit may be required for surgical treatment and/or hospitalization when necessary.