Microchip Clinic Registration

Owner Information

Animal Information

Agreement & Signature

I, acting as owner and agent of the pet named above, hereby request and authorize Buffalo County Humane Association (BCHA) to implant a microchip in the animal named above and to register that microchip using the owner information provided above.

I hereby release BCHA, its employees, staff, volunteers, agents and/or representatives from any and all claims arising out of, or connected with, the performance of this procedure or any adverse reactions.