MEDICAL FLEX INTAKE & RELEASE

MEDICAL FLEX INTAKE & RELEASE FORM
Full First and Last Name*
Pet's Name*
Pet's Age
Pet's Sex*
Pet's Breed
Cell Phone*
Best contact cell number where you can be reached TODAY.
*If Necessary, Animal Care Center has permission to perform diagnostic bloodwork, radiographs or sedation: Additional Fees apply ($100.00- $300.00)

Animal Care Center will attempt to contact me before prescribing treatment.
Diagnostic bloodwork, sedation or Radiographs*

YesNo
Has your pet been outside of Northern Nevada in past 30 days?*

YesNo
If yes, where?
Check the conditions that apply to your pet's visit TODAY.

CoughingSneezingVomitingDiarrheaEye DischargeNasal DischargeDirty or Itchy EarsSkin IssuesLimpingNew or Changed Lump
How long has this condition been going on for and with what frequency?*
Has your pet experienced this in the past?*
Please list all medications, vitamins, supplements, and preventatives that your pet is currently taking.*
Type NONE if none
PLEASE COMPLETE OTHER SIDE
Are there any other issues/concerns that you would like the Doctor to address?
CONSENT AND AUTHORIZATION TO TREAT

Authorization: I authorize Animal Care Center to do whatever is necessary should an emergency arise. Should mypet become ill or injure itself, and Animal Care Center is unable to contact me at the numbers that I have provided, my pet will be treated as deemed necessary by the attending Doctor at my own expense.
Signature here*

Clear
I certify that I am over eighteen (18) years of age and therby consent to the examination of my pet by the staff of Animal Care Center.

I authorize the staff and Veterinarians of the Animal Care Center to perform any necessary diagnostic testing and treatments for my pet. This includes but is not limited to blood work, radiographs, prescribing medications for, treatment, hospitalize, anesthetize, and perform surgery on my animal. Should some unexpected illness needing medical attention or life-saving emergency care be required, Animal Care Center's staff has my permission to provide such treatment and I agree to pay for such care.

I understand it is my responsibility to call the Animal Care Center within 5 hours of admittance time to inquire as to the medical status of my pet. I further agree that I, or an authorized agent of mine, will pick up my pet and pay for all accrued charges when pet is ready for discharge.
Printed Name of Owner or Agent*
Signature of Owner or Agent*

Clear
Date*

MonthDayYear
Date
I will be available by phone while my pet is at Animal Care Center*

Yes
Type Initials Here to Acknowledge *
Initials
Should be Empty:

MEDICAL FLEX INTAKE & RELEASE FORM

PLEASE COMPLETE OTHER SIDE