Authorization Form

I need to update my contact information such as mailing address, email address or phone numbers as follows:
I authorize the use of any photos of my pet taken by or given to Sunrise Pet Clinic for in house slideshows, Sunrise Pet Clinic website and/or social media purposes.*
- YES
- NO
I authorize Sunrise Pet Clinic to disclose the medical records of my pet(s) to the following groups upon their request (check all that apply):*
- ANY Emergency/Vet Clinics
- ANY Boarding/Day Care Facilities
- ANY Petsitters
- ANY Pet Insurance Company
- ANY Groomers
- None of the above
I ONLY authorize Sunrise Pet Clinic to disclose the medical records of my pet(s) to the specific persons or groups listed below and acknowledge that limiting disclosure may delay transfer of records until permission can be obtained from me verbally.
I authorize the following individuals to admit my pet(s) to Sunrise Pet Clinic on my behalf for any necessary or diagnostic treatment. I understand that I will be responsible for any service or product fees that these individuals request on my behalf. (Please include any petsitters, children over the age of 18, groomers, boarding facilities and/or day care if applicable.)
In the unlikely event that I experience a medical concern while visiting Sunrise Pet Clinic, my emergency contact's Name and Phone number:*
I understand that I am responsible for full payments at the time of services and that estimates will be provided to me prior to services upon request.*
- I agree
Please type your full name below as a signature.*
Date*
Phone number (in case we have any questions)*