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*BoardingDay CareI would like my pet to receive the following treatments on this date:* Date Format: MM slash DD slash YYYY *Same day treatments are available if requested before 2:00pmCheck All That Apply:*Doggie Day Care: out of date vaccines that are required for group play will automatically be administered to doggie day care guests.Dogs Wellness & Dental Health Exam Rabies Vaccine Distemper/Parvo Vaccine Bordetella (kennel cough) Vaccine Leptospirosis Vaccine Rattlesnack Vaccine Heartworm Test Fecal Cytology Urinalysis Express Anal Glands Ear Cleaning Basic Nail Trim Nail Trim with Dremel Microchip OtherPlease explain:Cats Wellness & Dental Health Exam Rabies Vaccine FVRCP Vaccine (Feline Distemper/Upper Respiratory) Leukemia Vaccine Fecal Cytology Urinalysis Ear Cleaning Basic Nail Trim FIV/FELV Blood Screen Soft Paw Application OtherPlease explain:Additional InformationConsent 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*