First Name*

Last Name*

Animal name(s)*

As the owner of the aforementioned animal(s), I*

Do give
Do NOT give

Dr. Megan Knoell permission to professionally discuss or disclose any treatments or diagnoses of my animal(s) conducted by Knoellwood Equine, as indicted in the Knoellwood Equine Authorization for Treatment/Exam form.

If agreed upon, any communication by Knoellwood Equine to my animals' trainer, veterinarian, farrier or other equine health care team member will be directed by me as the owner of said animal(s).

Name, address and phone number of equine health care team member 1

Name, address and phone number of equine health care team member 2

Name, address and phone number of equine health care team member 3

Name, address and phone number of equine health care team member 4

Name, address and phone number of equine health care team member 5

This authorization will remain in effect until cancelled or amended in writing by me, the owner of the aforementioned animal(s)

Your Signature*

Date*

Phone

This field is for validation purposes and should be left unchanged.

Permission to Contact Form