Treatment authorization

Treatment Authorization
Pet Owners Name *

First Name Last Name
Will you be our primary contact while your pet is with us? *

Yes No
Phone Number *

Area Code Phone Number
Additional Phone Number (optional)

Area Code Phone Number
Alternative Contacts Name *
Alternative Contacts Phone Number *

Area Code Phone Number
Pets Name *
Species *
What are we seeing your pet for today? Select all that apply. *

Health exam/recheck Vaccines Lab work X-ray and/or ultrasound
I authorize the hospital staff to perform services on my pet. I am the owner or authorized agent of the pet presented for care.

I understand that there is not a doctor or staff member on the premises after operating hours.

It is also understood that if I do not pay this account as agreed that past due accounts are subject to costs of collection, including attorney's fees.
Signature

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DateTime
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Treatment Authorization