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Co-owner Name
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      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 Information for Media or Website Publication

      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 videos to share with everyone on social media and newsletter publications. No personal or sensitive information is ever used. Only the pet’s name and information regarding the services provided may be used at any time.

      I hereby give permission to Jefferson Animal Clinic to use my pet’s photo and I expect no remuneration. I understand these photos and videos may be altered and used in various print media for the benefit of the practice and pet owners like me.

      My permission will be in effect until I request, in writing, to have my photos removed from the practice’s archive.

      Please make your selection and sign the release form below.*
      This field is for validation purposes and should be left unchanged.