Animal Medical's Cleaner Smile Challenge Entry Form

Date

Name

Email Address

Number

Name of Pet in the video

Is the pet shown in the video a patient at Animal Medical of New City? YesNo

List the names of anyone that we see or hear in the video?

The video that you submit will be uploaded to our practice's YouTube channel and other social media sites. Do we have your permission to publish your video on our Youtube Channel and other social media sites? YesNo

Please upload a copy of your video submission.

Drop a file here or click to upload Choose File

Maximum file size: 268.44MB

Animal Medical sends all of its clients a quarterly newsletter. May we add you to our mailing list? Email addresses are NEVER sold to third parties and only used for the purposes of sending our clients news articles and other valuable information about Animal Medical's pet care efforts Yes, it's okay to add me to the listThank you, but not at this time

By selecting ‘I acknowledge the above’ you acknowledge that Animal Medical of New City has the right to publish your video on its website and its social media venues for the purposes of promoting good pet dental health. You also acknowledge that everyone in the video has consented to having their image published online by Animal Medical of New City. You acknowledge that you are at least 18 years of age. If anyone in the video is less than 18 years of age, you attest that you are authorized to provide us permission to publish the submitted material and that you grant us such permission with the submission of your video. Winners of the contest are provided a FREE DENTAL PROPHY WITH X RAYS, the essential services of the pet teeth cleaning procedure. PLEASE NOTE THAT YOU WILL BE RESPONSIBLE FOR ALL OTHER CHARGES REQUIRED TO DELIVER THIS SERVICE INCLUDING INCLUDING ANESTHESIA, PATIENT MONITORING EXAMINATIONS, PRESURGICAL DIAGNOSTIC TESTS, EXTRACTIONS OR ANY OTHER MEDICAL PROCEDURE REQUIRED TO ENSURE SAFETY AND THE HIGHEST VETERINARY DENTISTRY STANDARDS. I acknowledge the above