You can always press Enter⏎ to continue
Welcome
Hi there, please fill out and submit this form.
15Questions
  • 1
    Press
    Enter
  • 2
    Press
    Enter
  • 3
    Press
    Enter
  • 4
    Press
    Enter
  • 5
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    Press
    Enter
  • 8
    Press
    Enter
  • 9
    Press
    Enter
  • 10
    Press
    Enter
  • 11
    Press
    Enter
  • 12
    Press
    Enter
  • 13

    I, the undersigned owner or authorized agent of the above patient, hereby authorize the Doctors of the Animal Clinic of West Plains, Inc. to administer necessary treatment and perform medical procedures. In signing below I am indicating that I understand fully the risks invovled in performance of the above described procedures. I further understand that no guarantee of successful therapeutic or diagnostic outcome is made. I also assume financial responsibility for all charges incurred, and agree to pay all charges at the time of release, unless other arrangements have been made PRIOR to admission to the Clinic and PRIOR to treatment of the above described animal. Payment is accepted by cash, check, credit card, or CareCredit. We are not responsible for any acts of God that may occur while your pet is staying with us.

    Press
    Enter
  • 14
    Clear
    Press
    Enter
  • 15
    Pick a Date
    Press
    Enter
  • Should be Empty:
Question Label
1 of 15See AllGo BackPreview PDF
close