Microchip Clinic Consent

Name *

First

Last

Phone

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

I understand that Bright Eyes Dog Rescue will scan my pet(s) prior to microchipping in order to ensure there is not a previous chip. *

I agree to accept all risks of microchipping and personally accept both legal and financial responsibility for all charges incurred as a result of such risks. *

I understand that the microchip is not a tracking device or a GPS transmitting device. Animals with microchips cannot be tracked or monitored from a remote location. *

I understand that should my pet(s) develop any severe or unanticipated problem resulting from the microchip, it is my responsibility to seek veterinary care as needed or directed. *

I understand that my pet(s) may develop side effects after microchip insertion. I understand that these side effects are very rare, usually minor in nature and pass without the need for additional veterinary care. *

I further acknowledge that Bright Eyes Dog Rescue will bear no legal or financial responsibility for any charges incurred by me. *

I understand that it is my responsibility to keep my contact information updated with the microchip registry company, and that if I do not keep my contact information updated it will drastically decrease the likelihood of my pet being reunited with me. *

How many pets will you be microchipping? *

Signature

Total

$ 0.00

Date / Time

50204

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