Owner*:  

Email Address:

Emergency Contact Name*: Phone*:

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Pet Health History

Sex*: Male Neutered Female Spayed

Vaccination History*:

Pet's Current Medication:

Pet's Current Diet:

2nd Pet Health History (Ignore if not applicable)

Male: Neutered: Female: Spayed:

Vaccination History:

Pet's Current Medication:

Pet's Current Diet:

3rd Pet Health History (Ignore if not applicable)

Male: Neutered: Female: Spayed:

Vaccination History:

Pet's Current Medication:

Pet's Current Diet:

Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet (s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.

I confirm that I have read and agree with the above authorization statement*

INFORMED CONSENT PLEASE READ, CLICKING BELOW CONSITUTES YOUR SIGNITURE. Sierra Animal Hospital will use all reasonable precautions against injury, escape, or demise of your pet. Sierra Animal Hospital will not be held liable or responsible in any manner whatsoever in any circumstance including treatment, and safe keeping of any animal or otherwise in connection therewith as it is throroughly understood that I, the owner, assume all risks. I understand that if the animal is not current on ALL vaccinations posting in the office, of if I am not able to provide proof of vaccinations, they will be given the missing vaccinations before being hospitalized, accepted for surgery, boarded, or groomed and the cost will be added to the described proceedures. I consent to the aministration of treatment for my animal(s), if during boarding my animal has diarrhea or vomiting - This is usually due to the stress of being away from home for a period of time. I also understand that conditions not know may make it advisable that other surgery or treatment related to the descibed proceedures be done and I authorize such other surgery, treatment or test when and if they are deemed advisabe. I consent to the administration fo such anesthesia as may be deemed proper by the doctor. I acknowledge that no assurance or guarantee has been made of the results of surgery or treatment and the probabilities of complications exist in any surgical or medical treatment. All charges including boarding costs shall be paid when the animal is released from the hospital. If the animal is not called for within five days after the time specified for return and if Sierra Animal Hospital is not notified of an alternate date within the five-day period, the animal will be considered abandoned and may be disposed of as Sierra Animal Hospital sees fit. It is understood that in abandoning the animal does not relive me from paying all costs of services, use of the hospital, disposal of the animal and the cost of boarding. I acknowledge that upon request a written estimate of fees for any hospital treatment, emergency care, surgery, grooming, boarding or hospitalization will be provided. I agree that should the account be refered to a collection agency and/or an attorney for collection, I shall pay all attorney and collections fees. Any payment arrangement made on an oustanding balance will be assessed a two (2) percent monthly finance charge on balances not paid by the tenth day of every month following the purchase. In no event, will the finance charge exceed the maximum lawful rate of the state of Arizona.

After carefully reading I agree to all of the above.*

Method of payment*: Cash Credit/Debit Card Check CareCredit

SIERRA ANIMAL HOSPITAL ONLY ACCEPTS CHECKS THAT HAVE BEEN ELECTRONICALLY APPROVED AND ONLY PROVIDES PAYMENT PLANS THROUGH A FINANCIAL PARTNER SUCH AS CARECREDIT

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