Agreement to Transfer Pet Ownership Client InformationClient NameAddress Street Address City State / Province / Region ZIP / Postal Code Phone NumberPatient InformationPatient NameSpeciesBreedSexColorWeightIs your pet spayed/neutered? Yes Date MM slash DD slash YYYY I acknowledge that I am transferring ownership of the pet described below to this veterinary practice:Microchip/Tattoo ID NumberAgeVaccination HistoryDeworming HistoryI understand that:(Please check each statement) I am transferring ownership of my pet to this veterinary practice, where he/she will be treated at no further charge to me and either a) adopted to a new owner, b) if a new home cannot be found within a reasonable time period, euthanized at the option of the practice’s staff or c) transferred to a local humane society for adoption or euthanasia. If my pet is adopted, he/she will be placed as a pet and companion animal only, and will not be used for any other purpose. This veterinary practice must and will maintain strict confidentiality with respect to the identity of the adoptive owner and I will not have access to that information. Once ownership has been transferred, I will no longer receive any reports as to the condition or status of this pet. I am financially responsible for the fees related to this pet’s medical care up until the transfer of ownership to this veterinary practice. I agree to transfer the above-named animal as of...TimeDateOwner/Agent Signature(Required)PhoneThis field is for validation purposes and should be left unchanged. Δ
