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Animal Care Clinic Owner/Pet Info Form

Thank you for giving Animal Care Clinic the opportunity to care for your pet(s). So that we may become better acquainted, please complete this form.

FEES ARE DUE AT THE TIME SERVICES ARE RENDERED
We accept cash, check, Visa, MasterCard and Discover

* Required

Owner Information

Example: December 15, 2012
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Pet Health Information

Example: December 15, 2012
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Mark only one oval.
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Example: December 15, 2012

Pet Health Information - Pet #2

Disregard if you have one pet.
Example: December 15, 2012
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Mark only one oval.
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Example: December 15, 2012

Pet Health Information - Pet #3

Disregard if you have one pet.
Example: December 15, 2012
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Mark only one oval.
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Example: December 15, 2012

For All Appointments

Please accept or decline the options listed below
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Consent for Procedures

Please review this section carefully.

- I, the owner or the agent for the owner of this animal authorize the veterinarians and staff of Animal Care Clinic to perform the procedure(s) listed above and use all related medications, tests, and treatments.

- I understand payment is due at the time of service. I may request an estimate before treatments are performed if desired.

- I understand the risks related to immunization and the signs of an allergic reaction that would require emergency medical treatment have been explained to me.

- I understand the CDC's recommendation on strategic deworming and parasite prevention.

- I understand that all payment is due the day services are rendered. Interest on accounts unpaid for more than 30 days will be charged at a rate of 1.5% per month, which equals 18% per year.

- By entering my name below and submitting this form and waiver, I give Animal Care Clinic the right to use my pet's picture and information that I provide to the hospital (via story for Facebook, blog or newsletter, or via testimonial) for reproduction in any medium including but not limited to: website, video, broadcast, print, and electronic means for purposes of advertising, trade, display, exhibition or editorial use. Further, I also (i) agree to release Animal Care Clinic from all claims for libel, slander, invasion of privacy, infringement of copyright or right of publicity or any other claim and (ii) confirm that I am over the age of 18 years old.

Example: December 15, 2012

Authorization for Procedures/Anesthesia

By entering my name and date below and submitting this form, I hereby authorize Animal Care Clinic to perform such anesthesia and procedures as listed above. The nature of such services has been described to me to my satisfaction and I realize that no guarantee can be made regarding the results or cure. I understand there are inherent risks with anesthesia, including death. I authorize the hospital staff, in an emergency situation, to perform procedures that are necessary for the well - being of my pet on a continuing basis until further communication with me. I understand that I assume financial responsibility for all services rendered.

Example: December 15, 2012