After an explanation of its intended use, I authorize the staff at this veterinary practice to release portions of my pet's medical history and record, including personal recollections, radiographs, photographs, videotape images or other images to use with media entities below named.

I understand that this information may be used on a television or radio program, in the print media, on a brochure or on the website of this veterinary practice and /or another websites for public education purposes and agree to its use in that manner.

I, the undersigned, am interested in educating the public about my pet's condition and medical care and authorize this veterinary practice or institution's faculty, clinicians, employees, students, and/or agents to use such materials for this purpose. I agree not to file any claim for revenue or lawsuit for damages against this veterinary practice with respect to the release of this information.

* Required Fields