620 W Webster Ave. Chicago, IL 60614

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Client Information:

Patient Information:

Patient History:

Vaccine/Testing History:

Treatment Authorization

Optional Photo/Video Authorization

We can’t help but want to spread the word how adorable our patients are! Your signature here grants full permission to Oz Animal Hospital to utilize photographs or images (last name and medical conditions shall be kept confidential) of this patient and/or yourself for use in any publication, social media, or advertising medium. I waive all right of privacy or compensation in connection with any used images.

You may download a printable pdf version of this form HERE. You can either scan and email us the form back or bring it in with you upon your visit.

If you are having problems with either of these forms, please contact us immediately at 1-773-327-5024.