"*" indicates required fields

MM slash DD slash YYYY
Owner's Name*
Please check any symptoms you have noticed with your pet

Please INITIAL any and all treatments and diagnostic procedures we are authorized to perform

Is your pet currently on ANY medications (**including supplements)?*
Please list the medications and include dosage (how much & how often)**
Medication
Dose (How much & often)
Last Given
 
What type/brand of heartworm preventative are you using?

What type/brand of flea/tick preventative are you using?

Dry or wet*
**We will attempt to perform the above procedures without sedation. However, in some cases it may be necessary to place your pet under light sedation for the comfort of your pet. Your signature below indicates your acceptance of this procedure without additional prior notice.

I understand the above diagnostic, therapeutic, anesthetic and/or surgical procedures may involve risk of complications, injury, or even death, from both known and unknown causes, and no warranty or guarantee has been either expressed or implied as to result or cure. Furthermore, I authorize the hospital staff in an emergency situation to follow through with such procedures as are necessary for the well-being of my pet on a continuing basis until further notice communication from me. I agree to assume financial responsibility for all routine and emergency services rendered.

Your signature below constitutes your acknowledgement that (i) you have read and agreed to the above, (ii) the procedure(s) have been explained to your satisfaction and that you have all the information that you desire, (iii) you have had the chance to ask questions, and (iv) you authorize and consent to the performance of the procedure(s) and to the administration of anesthesia (if indicated).

**We need the name and number of one person that can be reached and who can make decisions (medical and financial) about the care of your pet. Multiple phone calls affect the prompt care of all of our patients. Legally, this should be the person named on the record as the owner.

ALL SERVICES RENDERED MUST BE PAID IN FULL AT TIME OF DISCHARGE