Release Form

Owner name

Owner email

Owner Phone

Patient Name

Patient Weight

Client Sex
MaleFemale

Current Meds/Supplements (List all the apply.)
Date Last Taken
Date Last Taken
Date Last Taken
Date Last Taken

Flea/Tick Prevention Medication

Date Last Taken

Diet

I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, and that I do hereby give full and complete authority to perform the procedure(s) described:

Concerns/Procedures

And to perform any other procedure that at ’s discretion, may be useful to promote the health of . I do hereby forever release the said , his agents, and representatives from any and all liability arising from said procedures on . The nature of such service has been described to me to my satisfaction and I realize that neither guarantee nor warrant can ethically or professionally be made regarding the results or cure. I understand that anesthesia does carry some risk.

Routine bloodwork diagnostics are highly recommended for pets of all ages! Diagnostics can help detect many diseases early and contributes greatly to the overall health of your dog or cat; they may also be necessary if your pet is here for non-routine purposes.

I approve bloodwork/x-ray diagnostic testing.I decline bloodwork/x-ray diagnostic testing.

If declined, when was last blood test:

Additional Procedures:
Add on periodic polish/medicated bathNail Trim / Ear Cleaning / Anal GlandsMicrochip ApplicationSemi Annual / Annual ExamTests DueVaccines Due

FINANICIAL RESPONSIBILITY
I agree to assume full financial responsibility for all services rendered, and that payment is due on the date services are rendered. Any medications or supplies purchased or prescribed may be at an additional charge.