Midvalley Animal Clinic Hospitalization/ Treatment Plan / Drop off Authorization
Owner Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Best Contact Phone Number In Case of Emergency
-
Area Code
Phone Number
Can we text you updates
yes
no
Email
example@example.com
Date
-
Month
-
Day
Year
Date
Pets name
Hospitalization/ Treatment Plan
What are we doing for your pet
have you received an estimate for these services?
yes
no
I understand if an estimate of charges was given, the estimate is only an approximation and that unforeseen circumstances may result in final charges being substantially greater then the estimate.
I understand that any estimate given is in addition to any doctor consultation and treatments previously performed
I authorize Midvalley Animal Clinic to do the preceding services on my pet. I understand the following (1) No guarantee of successful outcome of treatment is either expressed or implied (2) Risks are involved in treatment of any condition including death.
I understand all fees for services rendered are payable by cash, check, or credit card at the time services are rendered. I understand any past due accounts are subject to all costs of collection, including legal fees.
I am the owner, or authorized agent of the owner of the pet presented for care.
Signature
Submit
Should be Empty: