Title:

First name:

Last name:

Date images  taken:

I, being owner / agent of the below named animal, hereby authorise Scone Equine Hospital to copy / electronically distribute images taken on the above listed date of the described animal below

Name / breeding:

Sex:

Breed:

Brand: NS

Brand: OS

Colour:

Age / DOB:

These images are to be sent to:

Name:

Address:

Email address:

I understand that there may be a fee charged for this service and hereby agree to pay the prescribed fee

I agree
I disagree

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