Authorization for Treatment

By marking an (x) on the following statements, you are agreeing to the following terms:

(Required)

I agree that all spelling and information shown is correct.

(Required)

I am the owner, or authorized agent of the owner for this pet. I certify that I am over eighteen years of age, and hereby consent to the examination on this pet by the veterinarian on staff at this practice.

(Required)

I understand that after the initial examination of my pet, the doctor may prescribe medication, treat, hospitalize, sedate, anesthetize, and/or perform surgery on my pet. I understand that an estimate of the costs for these services will be provided to me. In signing the estimate presented to me, I am agreeing to pay the fees for the services before they are renderer for this exam and all future exams. I understand that if my estimate has a range in price, I will not be notified so long as the bill stays within the quoted low to high range. If charges over the high estimate are needed, notification will be made.

(Required)

I understand Mira Loma Animal Hospital is not a 24 hour facility. I understand there is no staff on site after hours and I am responsible for picking up my pet before the facility closes. I am aware of the hours of operations. In the event my pet is not picked up before closing hours, I understand an additional fee of $65 will be added to my bill. Any treatments/care or medications needed will not be provided to the pet as staff does not remain on premisis. If pet is considered critical and needs to be transfered to an emergency facility, all bills for transport and emergency care will also be added to the bill. Any treatments completed for the pet while in our care at our facility will also be added to the bill. If pet is not picked up by closing, no estimate will be provided and you will be legally obligate to pay the balance(s) for treatment. According to Civil Code 1834.5, we are able to rehome and or euthanaize any abandoned pets. All rights of owner of the pet will be relinquished.

(Required)

I understand there is no guarantee in medicine, the doctor and staff will treat my pet to the best of their abilities. I will not hold Mira Loma Animal Hospital responsible for my pets recovery. I understand that some risks or complications may occur while my pet is being treated at this facility. Should unexpected life-saving emergency care be required, the practice has my permission to provide such treatment.

(Required)

Mira Loma Animal Hospital has the right to notify local animal control authorities of any neglect/cruelty cases seen fit.

(Required)

I understand that a complete copy of my medical record will be available for me and will be emailed to the email address I have provided. In the event a hard copy of the medical record is needed I understand there will be a $3.50 clerical fee per visit for the printed records.

(Required)

I am aware for appointment cancelations an additional fee of $10 will be charged to my account for any appointment cancelled with less than a 24 hour notice.

(Required)

I authorize Mira Loma Animal Hospital to post photos and updates of my pet on social media.

Accepted payment types- Cash, Visa, Discover, Mastercard, American Express, Paypal and/or CareCredit. Checks are not accepted. Card holder must be present with valid ID in order to process payment(s). Transactions using Paypal are subject to 4% service fee. Discounts will not be applied to transactions using Paypal or CareCredit.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Pet's Name(Required)

Gender(Required)

Male

Female

Spayed/Neutered(Required)

Yes

Breed(Required)

Age of Pet(Required)

Color(Required)

Signature(Required)

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