Shaffer Animal Hospital - Treatment Authorization

1
Owner and Pet details* This field is required.
Your First Name
Last Name
Pet's Name
2
Owner's Consent* This field is required.I am the owner of the above-named animal or am responsible for it and have authority to execute this consent. I understand there will be an examination performed for the above described condition. I hereby give the doctors at Shaffer Animal Hospital my permission to perform diagnostic procedures and treatments as are reasonably necessary to treat the aforementioned condition. While I accept that all procedures will be performed to the best of the abilities of SAH, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to indemnify and hold harmless from and against any and all liability arising out of the performance of any procedures referred to above. I agree to pay a deposit of 50% of the estimated fees, assume financial responsibility for the remaining fees due on the date of discharge, and provide payment via cash, accepted credit cards, Scratchpay, or check at the end time my pet is discharged from the hospital. Should unexpected life-saving emergency care be required, and the hospital staff is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services. I understand that if I pick up my pet any later than the posted time of closure of the business, I may be subject to a late fee..
3
If hospital staff is unable to reach you, does it has the permission to provide such treatment and do you agree to pay for such services.* This field is required.
Yes
No
4
Please list the procedure to be performed/condition.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
5
Please Specify
I would like an estimate of all charges prior to any diagnostic testing or treatment performed.
I would not like an estimate of charges prior to any diagnostic testing or treatment performed.
I have received an estimate of charges;please contact me with an estimate if any additional services are needed.
6
Date of Appointment* This field is required.
Date
Month
Day
Year
7
How would you like to receive notifications about your pet’s stay with us? Would you prefer to be called or notified through our app?
Call (List Number)
Notified Through App (List Name)
Email Address
8
Signature * This field is required.
Clear
9
Date* This field is required.
Date
Month
Day
Year
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