Treatment- Surgical - Dental- Authorization Form

Staff Member making sheet (initial)

Staff member checking in (initial)

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Pet Name*

First NameSpecies/Breed

Pet Age*

Current Medications (including Aspirin, Supplements, Vitamins etc) or type n/a if none*

Please read carefully and sign:

I certify that I own or am the authorized agent of the above described animal and do heareby consent and authorize Harbor Animal Hospital and it's staff to do the following procedure(s) as the veterinarian(s) deem necessary for the health, safety or well being of my pet(s) while under their care and supervision. The nature of the procedure(s) has been explained to me and no guarantee or warrantly has been made as to the results or care. I understand that there may be risk involved in these procedures. I understand if I refuse to have the recommended testing/diagnostic procedures that the veterinarian suggests, I will assume all legal and financial responsibility for any consequences athat occur.

Procedure to be performed:

Approximate Total:

Please perform any services recommended by the doctorCall for any services needed, if not reachable services will not be done.Please perform whatever services the doctor deems necessary up to:

Enter dollar amount ($) *

Start CPRMy pet is DNR (do not resuscitate)

Emergency Contact Name:

First NameLast Name

Emergency Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

A microchip is a safe, simple and permanent form of pet identification that can quickly identify lost pets and reunite them with their owners. The cost of microchipping includes the implant and a lifetime registration with Home Again. It utilizes a tiny microchip (the size of a grain of rice) that is implanted between the pets shoulder blades.

YesNo

Treatment, surgeries, radiographs, laboratory procedures etc related or non-related rendered after release from the hospital are NOT included in the cost of the fees charged upon release and must be paid when such procedures are performed. I further realize that I am responsible for the payment for the above procedures and treatments in full at the time the pet is discharged. If I neglect to pick up the animal within seven (7) days of written notice that it is ready for release and mailed to the above address, we may assume the pet is abandoned. Abandonment does not release me of financial obligations. I further agree that in the case of non-payment, a finance charge of 1.5% per month (18% per annum) will be charged and that any collection fees, court costs, or attorney fees will be paid by me.

Surgery Instructions

No food or water after midnight the night prior to surgery.

Please arrive for surgery drop off between 7:30am - 7:45am.

We require 72 hours notice for surgery cancellations or rescheduling. Failing to provide 72 hours notice, will result in forfeit of the surgery deposit.

If you have any additional questions, please call us at 847-746-1915

Signature of Agent/Owner*

Date*

Date