I hereby authorize SPAY ILLINOIS and it's employees to examine, prescribe for, and/or treat the pet described above. I assume
responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid for upon release of the
pet. Only Cash, Credit or Debit. Please note that personal checks are NOT accepted. By signing this form, I also grant Spay Illinois
permission to use any images or videos taken during my pets/my visit to Spay Illinois Pet Well Clinics.