PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136; DoD Directive 5136.01, Army Regulation 40-905; SECNAVINST 6401B; AFI 48-131.
PRINCIPAL PURPOSE(S): To facilitate and document your decisions regarding your animal's care and treatment and veterinary staff plan of action.
This information is also used by veterinarians and health care authorities to identify the animal and verify ownership of a described animal being
released for diagnostic, therapeutic, and/or surgical procedures.
ROUTINE USE(S): The information may be used to aid in preventive health and communicable disease control programs or to report medical
conditions required by law to Federal, state, and local agencies. The DoD Blanket Routine uses found at:
may also apply.
DISCLOSURE: Voluntary. However, if you fail to furnish the requested information, your animal will not be euthanized by military veterinary
a. NAME (Last, First, Middle Initial)
b. ADDRESS (Street, City, State, ZIP Code)
d. TELEPHONE NUMBER
g. MICROCHIP/ID NO.
I hereby consent and authorize you to receive, prescribe for, perform diagnostic testing/procedures, treat and/or operate on my privately-owned
animal for which I have shown proof of ownership or power of attorney.
You are to use reasonable precautions against injury, escape, or destruction of the animal and to perform all required procedures with reasonable
care and diligence in a professional manner in adherence with accepted standards of veterinary practice.
I agree to the proposed anesthesia, surgery and/or treatments as listed below. I will be notified of any significant deviation in the proposed
surgery/treatment plan or changes to my animal's condition. I understand that unforeseen conditions may be found which require a change in my
animal's care plan. I authorize the use of appropriate anesthetics and other medications. I further understand that anesthetics and surgery may
present a risk to my pet's life and I accept that risk. The procedure(s) and the risks involved have been explained to me to my satisfaction. I
understand that guarantees to health outcomes cannot be made. I also authorize the clinic staff, in an emergency situation, to perform procedures
necessary for the well being of my animal.
Treatment(s)/procedures to be performed: (To be completed by veterinary staff; if more than four continue in Remarks section.)
If I have not picked up the animal described above within three (3) working days from the date you first attempt to contact me at the telephone number
shown above, the animal will be considered abandoned and may be disposed of or destroyed as authorities deem best. It is understood that actions
taken on abandoned animals do not relieve me from paying all costs of services, medications, supplies, and the use of your facilities, including the
cost of kenneling.
I understand that I assume full responsibility for all services rendered.
I have thoroughly read and understand the above information presented to me as evidenced by my signature below.
a. OWNER SIGNATURE
b. DATE SIGNED
c. VETERINARY FACILITY REPRESENTATIVE SIGNATURE
d. DATE SIGNED
DD FORM 2622, JUN 2013
PREVIOUS EDITION IS OBSOLETE.
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