Hospitalisation and Surgical Release Form

Owner/Agent (must be over 21)*

First Last

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Tel.*

Work Tel.

Procedure*

*

I certify that I own or am the agent for the owner of the above animal. I consent and authorize Endsmeet Animal Hospital and its staff to hospitalize my pet, and to administer medications, vaccinations, tests, treatments, anesthetics and such surgical procedures as the veterinarians deem necessary for the health, safety and well-being of the above animal whilst under their care or supervision. *

Untitled*

I understand that all reasonable precautions will be taken to prevent injury, escape or death of my animal whilst in the care of Endsmeet Animal Hospital. However, I understand that injury, escape or death is not always avoidable, and in the absence of gross negligence I agree not to hold Endsmeet Animal Hospital or its employees liable should such an event occur.

Untitled*

If I neglect to collect the animal or make alternate pick-up arrangements, within 5 days of the expected discharge date, you may assume that the pet is abandoned and transfer care of the pet to the Government Dog Warden or to the S.P.C.A. Abandonment does not release me from my obligation to pay the bill for any and all goods and services provided.*

Untitled*

I understand that I am responsible for payment in full for any services at the time the animal is discharged, unless an alternate payment plan has been agreed in advance with a member of the Management or by a Veterinarian. I understand that each month a 2% monthly surcharge will be added to all bills with an outstanding balance of more than 30 days. I agree that all agency charges, legal costs and other expenses incurred by Endsmeet Animal Hospital in attempting to recover overdue amounts will be charged to my account. I understand that if I require an estimate I can ask for one, and it will be provided by one of the veterinarians.*

Owner/Agent Signature (must be over 21)*

First Last

Date*

Payment may be made by cash, cheque, Visa, or MasterCard. Post-dated cheques will be accepted to be cashed at a later date.