Name*
Co-owner Name
Address*
MM slash DD slash YYYY
Species*

Gender:*
Spayed./Neutered?*
Drop files here or
Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 256 MB.
    Species

    Gender:
    Spayed./Neutered?
    Drop files here or
    Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 256 MB.

      Communication Consent Form

      We at Jefferson Animal Clinic consider you and your pet(s) as part of our family. During the year, we would like your permission to communicate with you regarding things that can be of assistance to you and your beloved pet(s). We regularly send out e-newsletters with helpful tips for the health care of your pet(s) and would love to have you follow us on Facebook and Instagram! We also want to be able to send a “thank you” for any referral you might give, a best wish for a Birthday or holiday, special offers on health care products that we recommend and of course, reminders for upcoming appointments. By receiving your permission, we know that we are communicating with you because you want to receive information that will benefit the health and well-being of your pet(s). Please check (X) below to tell us which way you are willing to be communicated with:
      Preferred method of contact*
      We respect your privacy and will not sell, rent or trade any of your personally identifiable information. The above are for communications from our hospital to you, and will not be used for any other reason.

      Thank you for being a part of our family! We truly care about you and your pet(s) and look forward to communicating with you throughout the year!

      Release of Media and Information

      Here at Jefferson Animal Clinic, we like to educate our clients, share interesting cases, facts and tips about caring for your pet(s)! We also love to take pictures and share adorable photos with everyone! No personal or sensitive information is ever used. Do you give Jefferson Animal Clinic permission to release media and information about your pet?*
      This field is for validation purposes and should be left unchanged.