Owner / Caregiver

Please provide the information below as completely as possible. All information is strictly confidential.

Pet Information

Referral Information

Statement Of Ownership

By checking below you certify that you are the owner and or agent of the above animal and have the authorization to consent to treatment if and when it is needed.

I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed above. Furthermore, I agree to pay fees for all services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection, attorney fees, and court costs in the event that collection efforts become necessary. I agree that the venue of this action will be in the county where the hospital is located. I understand that Veterinary service is provided during nighttime hours as necessary in the judgment of the Veterinarian in charge. Continuous presence of qualified personnel may not be provided.

Enter the verification code in the box below.