Owner Information:
First Name
*
Last Name
*
Address
Street Address
*
City
*
State
*
Zip Code
*
Phone Number
*
Email
*
Patient Information:
Pet Name
*
Pet Species
*
Pet Age
*
Pet Breed
*
Pet Weight
Sex
*
Male
Female
Suggested Appointment Date
*
Preferred Time
*
Morning
Afternoon
Evening
Please list pet’s current medications:
Previous Veterinarian
(Name, City, State and Phone Number)
Consent
I the undersigned, do hereby certify that I am the owner of the above animal or duly authorized agent for the above animal. I hereby authorize Angel of Mercy Animal Critical Care, their agent or representative to perform medical or surgical procedures, anesthesia, radiographic procedures, administration of drugs or other such treatments which the veterinarian deems necessary. I agree to accept responsibility for the full payment of all services rendered at each visit. If the above animal is admitted to the hospital a deposit equaling no less than half the estimated cost of treatment will be required with the remainder of the actual cost due upon discharge. I hereby state that I have read this release and I understand this agreement.
*
I understand and agree.
Signature
*
Clear
Submit