Admission For Treatment/ Services Form

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Admission For Treatment/Services Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Client Name *

Owner is over eighteen years of age.

Address *

Address Line 1

City

State

Zip Code

Phone number where I will be available today to discuss treatment *

Patient Name *

Patients Age *

Patient Species *

Patient Breed *

Patient Sex *

Patient Color *

Reason for Procedure *

DECLARATION

I am the owner of the above-mentioned animal. I have discussed the reasons for my pet's hospitalization with a veterinarian and I am satisfied with the plan of management for my pet's condition. I have also had the likely fees explained to me, and I understand that the deposit I am leaving may or may not cover the cost of treatment for my pet. I accept full responsibility for payment of the remainder of the balance at the time of my pet's discharge.

While my pet is in the ANIMAL CARE CENTER receiving treatment, I agree to indemnify the ANIMAL CARE CENTER, its servants or agents, from any loss or liability which they may incur as a result of any inaccuracy, whether intended or otherwise, in this, my solemn declaration.

Signature of Pet Owner or Person Responsible *

Clear Signature

Today's Date *

Admission For Treatment/ Services Form

Admission For Treatment/Services Form

DECLARATION

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We proudly serve the pets of Joppa, MD and beyond