Clients Name:*
Contact Number:*
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E-mail:*
Address:*
Spouse/Alternate Person:
Spouse/Alternate Person number:
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Pet's name:*
Microchip #:
Sex, Spay/Neuter:*
Details:*
Previous Vet:*
How did you hear about us?*
Referred by:
Permission to take and use photographs (See below for photo release):*
By clicking submit I hereby authorize the veterinarian to examine, prescribe for, or treat the above pet. I assume all responsibility for charges incurred in the care of this animal. I also undertand that these charges will be paid in full at the time of release, or discharge.

* Indicates required fields

-PHOTO RELEASE

 

1.PERMISSION TO TAKE AND USE PHOTOGRAPHS.

In consideration of the engagement of the Model as a model, and other good and valuable consideration, receipt of which is hereby acknowledged and received, the Model grants the Photographer and its employees, agents, independent contractors, licensees, successors, and assigns (the “Photographer’s Agents”) the full irrevocable right and permission to take video, pictures, portraits, digital images, or photographs of the Model and, potentially, the Model’s pet or in which the Model and such property may be included (the “Photographs”) and use, reuse, publish, republish, reproduce, edit, alter, and otherwise exploit the Photographs, in whole or in part and in conjunction with the Model’s name, in, on, or in connection with Schwenksville Veterinary Hospital and any advertising and publicity in connection therewith (the “Photograph Use”).

2.RIGHTS AND OBLIGATIONS.

The Model grants and assigns to the Photographer and the Photographer’s Agents all right, title, and interest in and to the Photographs, including, but not limited to, copyright. The Model understands and agrees that the Photographs and any associated negatives shall be the sole property of the Photographer and he or she shall have no right to: (i) inspect or approve the Photographs; (ii) inspect or approve any video, text, graphics, images, or other content created in connection with or combined with the Photographs; or (iii) receive any royalties or other compensation arising from or related to the Photograph Use.

3.RELEASE.

The Model agrees to release, discharge, and hold harmless the Photographer and the Photographer’s Agents from any and all damages, liabilities, costs, expenses, claims, and/or judgments of any kind or nature whatsoever arising from the Photograph Use, including, but not limited to, those based on copyright infringement, invasion of privacy, right of publicity, libel, defamation, or false light, or resulting from any alteration, blurring, optical illusion, use in composite form, distortion, or other modification that may occur, intentionally or otherwise, in connection with taking the Photographs, processing the Photographs, or the Photograph Use. The Model acknowledges and agrees that this Release is binding on the Model’s heirs, legal representatives, and assigns.

4.GUARDIAN’S REPRESENTATIONS AND WARRANTIES.

The Model hereby represents that he or she is 18 years of age or older and has the full legal capacity to execute this Release. The Model further represents that the rights granted under this Release will not conflict with or violate any other commitment the Model has with any other party. The Model has read this Release prior to submitting it and fully understands its contents, meaning, and impact.