Medical Drop Off Form 

OWNER INFORMATION
Name *
Name
PET INFORMATION
Please check any symptoms your pet is experiencing
I the undersigned, certify that I am the owner, or authorized agent for the owner, of the animal described above. I authorize the doctor on duty and assistants to perform any necessary procedure(s) within the authorized amount, including, but not limited to administration of pain relief medications, sedatives and/or anesthetics, as well as any necessary and appropriate medical, radiological, surgical, nursing,diagnostic, and/or emergency care for the animal. I have been advised as to the nature of the procedures and the potential risks. I also understand that no guarantee of successful treatment can be made. I also understand that the estimate is just an estimate and other costs may arise related to the care of my pet. I have read and understand the reasons for and the risks of the above and attached authorized procedure(s), and assume full financial responsibility for all charges and services incurred to the described animal. By typing my name in the box I an signing this Medical Drop Off Form.
Date *
Date