Client Information
Owner Full name
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Phone
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Pet Information & Health History
Pet Name
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Pet Breed :
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Pet Color :
Address :
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Type Of Pet
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Dog
Cat
Rabbit
Bird
Rabtile
Other
Gender
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Male
Female
DOB/Age :
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Microchip Number
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Vaccination information available? (Do you have your pet’s passport)
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Yes
No
Reason for visit & any main concerns:
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I confirm that my pet has been on fast for more than 8 hours.
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I hereby understand, consent, and authorize the performance of the following procedures: Anesthesia; Surgery under sedation or anesthesia; Blood tests; Treatment as deemed necessary. I understand that there is no guarantee of successful treatment and that no such guarantee has been made or offered. I agree and understand that Petology Veterinary Clinic will not be liable in case of the patient's death. Should my pet require boarding or hospitalization, I agree to pick up my pet when he/she is ready for Discharge. Failure to retrieve the patient within 5 days of notification that it is ready for discharge without notice will deem the patient abandoned, and I authorize Petology Veterinary Clinic to re-home the patient and/or undergo any medical procedures deemed necessary. The abandonment of a patient does not release the owner or agent of financial responsibility for that patient. I authorize Petology Veterinary Clinic, in the event I cannot be reached on the provided contacts, to treat my pet as deemed medically necessary while being in their care. I understand and agree, as the individual responsible for this patient, that in consideration for treatments and services rendered for the above patient, I obligate myself to pay every item and service incurred before the animal is discharged. I understand and agr ee that I am leaving any personal items with my pet at my own risk (ex: blankts, carriers, toys, etc). I certify that I am at least eighteen (18) years of age
By Signing this form, you accept the terms & conditions
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Date
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Email
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