Authorization for Medical/Surgical Treatment

Authorization for Medical and/or Surgical Treatment
Date*

MonthDayYear
Date
Client's First Name*
Client's Last Name*
Patient's Name:*
Species*
Breed*
Age*
Sex*
Spayed/Neutered*

YesNo
Is it Ok to text?*

YesNo
I authorize and direct the veterinarians of Eagle Animal Hospital, Inc. to perform such diagnostic, medical and surgical procedures as deemed advisable and necessary for Pet's Name* . The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I further understand that there may be risk involved in these procedures. I agree to pay in full for all services rendered, including those unforeseen medical or surgical complications. The estimate of charges for presently planned procedures is only an approximation and the final bill may be greater or less than this amount. If I neglect to retrieve Pet's Name* within 5 days of the agreed day of discharge, you may consider Pet's Name* abandoned. In such instances, Eagle Hospital is then authorized to take care of my pet as they see fit, including euthanasia or adoption. Abandonment, however, does not release me of my obligation for payment of charges.
Best phone number to reach you at today*
Confirm Email address*
example@example.com
Signed*

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Authorization for Medical and/or Surgical Treatment