Owner Name *

First

Last

Pet Name

Email *

Phone Number where you can be reached ALL day today: *

Species *

Canine
Feline

Are Vaccinations Current?

Rabies *

Yes
No
No - Update Today

(Canine) DHLP+Parvo *

Yes
No
No - Update Today

(Canine) Bordetella *

Yes
No
No - Update Today

(Feline) FVRCP *

Yes
No
No - Update Today

(Feline) FELV *

Yes
No
No - Update Today

arrangements understand injury

(Feline) FIP *

Yes
No
No - Update Today

Is your pet on heartworm preventive? *

Yes
No

If No, would you like to begin prevention? *

Yes
No

Has your pet been checked for intestinal parasites in the last 6 months? *

Yes
No

If No, would you like to have a fecal performed today? *

Yes
No

Did your pet eat this morning? *

Yes
No

Is your pet allergic to any medications? If so, please list below: *

Has your pet had any illness or injury in the past 30 days? If so, please list below: *

Any history of seizures and/or previous anesthetic problems? If so, please list below: *

Current medications? Please list if any: *

Additional Services

Notes on any Additional Services

Owner Release

For the enhanced protection of our patients, we require presurgical screening of all pets prior to administration of anesthetics. *

I understand and accept.

I decline taking home an ecollar and understand the risks of not using one.

I understand and accept.

I decline microchipping at this time.

I understand and accept.

I understand Foothills Animal Clinic will use all reasonable precaution against injury, escape, or death of my pet. I understand that anesthesia and surgeries always involve some risk to my pet and agree to not hold you liable in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event complications arise and I cannot be immediately contacted at the below listed phone number, you are directed to make the decision you deem best for my pet. I have read the foregoing, understand what it says, and agree. *

I understand and accept.

Vaccination Decline: “I understand that state law requires rabies vaccination for all pets. I also understand clinic policy requires Distemper/Parvo vaccination for dogs and/or Feline Distemper vaccine for cats be current. I decline vaccination at this time because vaccinations have been given elsewhere and are current. If my pet bites another animal or person while at this veterinary clinic, I can and will provide written evidence of a current rabies vaccination within 24 hours of notification to do so.”

I understand and accept.

I hereby irrevocably consent to and authorize the use and reproduction of any and all photographs or radiographs taken of my pet without further compensation to me by Foothills Animal Clinic, or anyone authorized by Foothills Animal Clinic or their partners or associated business entities for marketing purposes. All negative, positive, and digital images together with the prints shall constitute Foothills Animal Clinic property, solely and completely. I hereby certify that I am the parent/guardian/owner of the above pet and I do give my consent without reservations to the foregoing on behalf of him/her/them. *

I understand and accept.

Authorization to provide care:

I am the owner (or authorized agent of the owner) of the pet listed above. I hereby authorize and direct Foothills Animal Clinic, its veterinarians, technicians, and assistants to perform services, procedures, diagnostics, vaccinations, treatments, and/or administration of extra label medications as deemed necessary or advisable in connection with or relating to the matters described in the attached estimate or the matters that have otherwise been explained by Foothills Animal Clinic veterinarians or Foothills Animal Clinic associates.

I understand that there is a risk of complications with every procedure, including the possibility of death as a severe complication of surgery, anesthesia, or other procedures. I also understand that there is no guarantee as to the results of any procedures, diagnostics, vaccinations, or treatments. I understand that I may ask any questions regarding any procedure, diagnostic, vaccination, or treatment recommended by the Foothills Animal Clinic veterinarian before it is performed.

I understand that there may not be a veterinarian at the hospital at all times. I understand that veterinary technicians or assistants may perform certain functions in the preparation and care of <animal> even when a veterinarian is not present. I also understand that no staff will be present in the hospital overnight. Unless the veterinarian advises that <animal> may remain unattended in the hospital overnight, I will need to take <animal> or transfer <animal> to a hospital offering overnight care at the end of the day. If I fail to pick up <animal> before the hospital closes for the day, Foothills Animal Clinic may transfer <animal> to a hospital offering overnight care if the veterinarian determines <animal> cannot be left unattended overnight. I understand and agree that I am responsible for the payment of any charges of such overnight care.

I agree that hospital staff may walk <animal> outside. I understand that in the event of an emergency, it may be necessary for <animal> to be taken to an emergency hospital. I authorize Foothills Animal Clinic and its veterinarians and other personnel to transport <animal> to an emergency hospital and to obtain treatment by the emergency hospital to stabilize <animal> if I cannot be reached. Foothills Animal Clinic and its personnel may disclose such information and records regarding <animal> to the other hospital as they consider necessary.

I understand that payment is due in full at the time of services are rendered. I understand it is my responsibility to call the hospital daily, to be updated on my pet, and the costs incurred for medical services during that day. If I do not call or I cannot be reached, I understand it is my responsibility to pay what is due.

I understand that Foothills Animal Clinic does not request or require personal information as a condition to payment by credit card, but card users may be required to provide proof of identity. If for any reason payment is not made at the time services are rendered or within 10 days thereafter, I understand that my account may be referred to a collection agency. In the event that my account is referred to a collection agency, I agree that Foothills Animal Clinic may add an amount to my outstanding account balance to reimburse Foothills Animal Clinic for the reasonable collection charge (but not including attorney’s fees) imposed by the collection agency.

If I neglect to pick up <animal> within 7 days, Foothills Animal Clinic may assume that my <animal> has been abandoned and is authorized to make such arrangements as it may deem best.

I understand and agree that portions of my visit or care and treatment of <animal> may be recorded for educational purposes.

I am the owner (or authorized agent of the owner) of the pet listed above. I hereby authorize and direct Foothills Animal Clinic, its veterinarians, technicians, and assistants to perform services, procedures, diagnostics, vaccinations, treatments, and/or administration of extra label medications as deemed necessary or advisable in connection with or relating to the matters described in the attached estimate or the matters that have otherwise been explained by Foothills Animal Clinic veterinarians or Foothills Animal Clinic associates. I understand that there is a risk of complications with every procedure, including the possibility of death as a severe complication of surgery, anesthesia, or other procedures. I also understand that there is no guarantee as to the results of any procedures, diagnostics, vaccinations, or treatments. I understand that I may ask any questions regarding any procedure, diagnostic, vaccination, or treatment recommended by the Foothills Animal Clinic veterinarian before it is performed. I understand that there may not be a veterinarian at the hospital at all times. I understand that veterinary technicians or assistants may perform certain functions in the preparation and care of <animal> even when a veterinarian is not present. I also understand that no staff will be present in the hospital overnight. Unless the veterinarian advises that <animal> may remain unattended in the hospital overnight, I will need to take <animal> or transfer <animal> to a hospital offering overnight care at the end of the day. If I fail to pick up <animal> before the hospital closes for the day, Foothills Animal Clinic may transfer <animal> to a hospital offering overnight care if the veterinarian determines <animal> cannot be left unattended overnight. I understand and agree that I am responsible for the payment of any charges of such overnight care. I agree that hospital staff may walk <animal> outside. I understand that in the event of an emergency, it may be necessary for <animal> to be taken to an emergency hospital. I authorize Foothills Animal Clinic and its veterinarians and other personnel to transport <animal> to an emergency hospital and to obtain treatment by the emergency hospital to stabilize <animal> if I cannot be reached. Foothills Animal Clinic and its personnel may disclose such information and records regarding <animal> to the other hospital as they consider necessary. I understand that payment is due in full at the time of services are rendered. I understand it is my responsibility to call the hospital daily, to be updated on my pet, and the costs incurred for medical services during that day. If I do not call or I cannot be reached, I understand it is my responsibility to pay what is due. I understand that Foothills Animal Clinic does not request or require personal information as a condition to payment by credit card, but card users may be required to provide proof of identity. If for any reason payment is not made at the time services are rendered or within 10 days thereafter, I understand that my account may be referred to a collection agency. In the event that my account is referred to a collection agency, I agree that Foothills Animal Clinic may add an amount to my outstanding account balance to reimburse Foothills Animal Clinic for the reasonable collection charge (but not including attorney’s fees) imposed by the collection agency. If I neglect to pick up <animal> within 7 days, Foothills Animal Clinic may assume that my <animal> has been abandoned and is authorized to make such arrangements as it may deem best. I understand and agree that portions of my visit or care and treatment of <animal> may be recorded for educational purposes. *

I understand and accept.

Should an unexpected life-threatening emergency take place: *

I authorize the hospital staff to perform CPR and provide treatment up to (list amount below):
I do not want CPR performed.

Amount Authorized for Emergency Treatment:

ALL FEES ARE DUE UPON RELEASE OF PATIENT

Signature: *

Clear Signature

Surgery Release Form

ALL FEES ARE DUE UPON RELEASE OF PATIENT

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