Owner Information
Owner Name
Spouse/Partner’s Name
How did you hear about us? (Check one)
Pet Information
Is your pet spayed or neutered?

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 services rendered at the time the pet is discharged from te hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary.

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