Request a Treatment For My Pet

Client Name*

First Last

Pet Name*

First

Phone number I can be reached at today*

Email*

My pet is in*

I would like my pet to receive the following treatments on this date:*

*Same day treatments are available if requested before 2:00pm

Check All That Apply:

*Doggie Day Care: out of date vaccines that are required for group play will automatically be administered to doggie day care guests.

Dogs

Please explain:

Cats

Please explain:

Additional Information

Consent to Treat & Liability Release*

ACKNOWLEDGMENT: As the owner, or agent for the owner, of the animal listed on this form, I am authorized to give my consent for Aspen Grove Veterinary Care (also referred to as AGVC) to perform the outlined procedures. I understand that during the performance of these procedures unforeseen conditions may occur, necessitating an extension or variation of the procedures and/or the emergency performance of additional procedures increasing any estimated costs provided to me. AGVC has my permission to follow through with such procedures for the well-being of my pet and I agree to pay all additional costs in accordance with the payment policies of AGVC. As consideration for providing medical care for my pet(s), I, for myself, my heirs, executors, administrators, legal representatives, successors and assigns (the “Releasing Party”), waive, release, discharge and agree not to sue and to indemnify, defend and hold harmless Aspen Grove Veterinary Care and its owners, officers, directors, employees, independent contractors, agents, representatives, successors and assigns (the “Released Party”) from any and all injuries, losses, claims and damages of any nature to any person or property, including claims arising from the Released Party’s own negligence, and all associated costs, including attorney’s fees, court costs and consultant fees, arising from any activity related to the care and treatment of my pet(s).

Signature*