Do you prefer phone calls or text messages for contacting you?

Phone CallText MessageEither

In the event of an emergency, I select the following resuscitation option:

I give permission for life sustaining procedures.I do not give permission for life sustaining procedures and understand that in such cases the veterinarian deems necessary, my pet may be euthanized to end their suffering.

Reason for Visit

Sick/Concern AppointmenProgress/Recheck ExamSurgery/Dental CleaningHeartworm TreatmentVaccinations/Yearly ExamOther

Microchip: The microchip is the professional way to identify your pet. A tiny microchip that contains a personal, one-of-a-kind ID number is placed under the skin. This includes a lifetime registration. This is highly recommended for all pets, even if they are indoor only and/or wear a collar. This can be done at any age. There is an additional fee for this service. Would you like to get this done today?

My pet is already microchipped. Please verify the placement.Yes please microchip my pet if they are not already.No, I decline microchipping at this time.Other

Does your pet need any of the following while with us today? (These are additional charges)

Nail Trim (complimentary with surgery)Anal Gland ExpressionEar Plucking/CleaningNoneOther

Please remember that any charges you were quoted were ESTIMATES only.

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Some procedures are inherently risky and complications, including the death of your pet, may arise. I have been informed of the risks and complications associated with my pet’s condition, the planned procedures or diagnostics, and any treatment thereof. I understand that results cannot be guaranteed.

I understand that close clipping of the hair/fur is sometimes required for certain diagnostic procedures or treatments. I give my consent to clipping of the hair/fur on my pet as required to facilitate diagnostics and/or treatment.

I have been informed of or have had an opportunity to ask about alternatives to the suggested procedures.

I assume full responsibility for all charges accrued from diagnostic procedures and treatments performed at Animal Medical West.

I am also aware that complications, deterioration of condition, death and any unforeseen events resulting from such diagnostics or treatment will not relieve me from any obligation to all costs incurred during hospitalization. Furthermore, I am aware that as more is learned about my pet’s condition, additional costs may arise.

I have been informed that Animal Medical West will attempt to contact me regarding additional charges and project estimate adjustments as required, if I request this.

I understand in some circumstances a monetary deposit will be required prior to initiating treatment.

Furthermore, I agree to pay the balance in full upon discharge from the hospital (or unfortunate death or consented euthanasia) of my pet. I also understand that unless informed otherwise recheck appointments, especially those requiring radiographs, bandage changes, blood tests, etc. will usually incur additional charges.

I understand that I am free to call at any time during my pet’s stay at the hospital for updates regarding my pet’s condition.

If I would like to visit my pet while hospitalized, I have been informed that I must call to schedule visitation. I understand that in the event that an emergency arises with another patient during my visit I may be asked to leave.

I understand that should I fail to collect my pet within 10 days of the informed date of intended discharge, I relinquish his/her full ownership to Animal Medical West. Furthermore, I agree to pay any additional charges incurred after said intended discharge date, whether or not I collect my pet within that 10-day period.

Owner Signature: