• Pet #1 Information

  • Pet #2 Information

  • Additional Info

  • I hereby authorize the veterinarian to examine, treat and/or prescribe for above described pet(s). I assume responsibility for all charges incurred for the care of the animal(s). I understand these charges are to be paid at the time services are renĀ­ dered and/or release of animal(s) and that a deposit may be required before any treatment or procedure(s) are performed.

  • Date Format: MM slash DD slash YYYY