Microchip Registration Form

Pet Information

Pet's Name (required)

Pet Breed (required)

Contact Information

Pet Owner's Name (required)

Owner's Address (required)

Owner's Phone Number (required)

Owner's Email Address (recommended)

Alternate Contact(s) Information

Alternate #1 Contact's Name (recommended)

Alternate #1 Contact's Phone Number (recommended)

Alternate #2 Contact's Name (recommended)

Alternate #2 Contact's Phone Number (recommended)

Authorization

By signing below, I agree to the terms and conditions on the back of this form and authorize: (1) the Veterinarian/Shelter listed above to share personal information about me and my pet, including medical information, with ScheringPlough Home Again LLC ("Schering"); (2) Schering to share that information with third parties, including affiliates, business partners, vendors, municipalities, other veterinarians, medical caregivers and shelters and; (3) Schering to contact me at the telephone number listed above HomeAgain products and services. Schering will advise you at least 10 days in advance of any change in the annual membership fee. I may terminate this authorization by calling Schering at 1888-HOMEAGAIN (1-888-466-3242). Such termination will be effective 3 business days after receipt and will not affect any action taken in reliance on my consent or the continuing enforceability of this authorization.

Pet Owner Signature (required)

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