Hospitalization Consent FormSeymour, IN

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goats in the veterinary clinic

Hospitalization Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

*We may need to contact you with permission to make medical and financial decisions. Please provide the best contacts so we may do so.*
I certify that I own or represent the owner and hereby authorize the veterinarians at Seymour Animal Hospital to examine, hospitalize,and treat my pet as set forth above or as they deem necessary.I also consent that the Seymour Animal Hospital doctors and staff may administer/perform diagnostic tests, anesthetics, surgical procedures, treatments, vaccinations, and/or medications that the doctors deem necessary for the health, safety, and well-being of my pet while it is under their care and supervision. If my pet should injure itself, refuse food, soil itself, become ill, or die while in the hospital, I will hold the Seymour Animal Hospital free of responsibility and/or liability in the absence of gross negligence. I agree to assume full responsibility for treatment expenses involved and to pay allfeesin full for theservices rendered at the time my pet is discharged from the hospital.If you neglect to pick up your pet that is ready for release within (5) days of a written notice having been mailed to the above address, you may assume that the pet is abandoned and will be authorized to dispose of the animal as see fit. Abandonment does not release me of my obligation for payment of services rendered. I agree that in case of non-payment, a 1.5% per month interest charge will be assessed on accounts not paid within 30 days. In addition, if referral to an outside attorney or collection agency becomes necessary, I willpay a collection fee up to 50% of the balance.
Clear Signature
Clear Signature