Hickory Grove Animal Hospital Drop Off/Estimate-Consent Form

Hickory Grove Animal Hospital Drop Off/Estimate-Consent Form
Date*

MonthDayYear
Date
Patient:*
Owner Name:*

First NameLast Name
Breed:*
Sex:*
Contact Phone Number*
Please enter a valid phone number.
This estimate of the charges is intended to approximate the anticipated expenses in the care of your pet. Some procedures may become more involved than originally anticipated. This is an estimate, not an exact quote. In the event of unpredictable circumstances that will cause your bill to exceed by20%, we will attempt to contact you before proceeding.
Office visit

$ _________________
Vaccinations ________________________________ _________________
Laboratory __________________________________ _________________
Bath, Nail Trim, Clean Ears _________________
Injection(s) _________________
Medication(s) _________________
_________________
Other _________________________________________ _________________
Estimate Total $ __________ to _____________
I am the owner/agent for the described animal, authorize, and request an exam for my pet. I understand that sedation and/or pain medication will be provided if deemed reasonable. I understand the doctor will contact me, if needed, after she/he has examined my pet to discuss recommended diagnostics and treatment, and will have an initial estimate of charges.

If I cannot be reached at this number, I authorize initial diagnostics, including radiographs, and blood work if indicated for my pet. Further, if I cannot be reached, I authorize initial treatment, including fluid support and other supportive medications are started as indicated for my pet.

I understand that payment is due when my pet is discharged, however, a deposit may be required after an estimate is prepared and discussed. I accept financial responsibility for charges incurred for this pet.

I understand that I will be charged for flea medication and a dose will be applied if evidence of fleas are found on my pet
today.

Dogs: Rabies, DHLPPV, Bordetella, Fecal test, and Heartworm test must be current.
Cats: Rabies, FVRCPC must be current.

The nature of the procedure(s) has been explained to me and no guarantee has been made as to the results or cure. I will
not hold Hickory Grove Animal Hospital, the doctors, or staff liable for any complications.

I have read and understood this authorization and consent
Signature*

Clear
Does your pet require any medication to be given while in our office?*

YesNo
If yes, name of medication and what time?*
Does your pet require feeding while at our office?*

YesNo
If yes, name of diet and what time?*
Any other special requests per owner:*
Should be Empty: