Owners Name:

Pet’s Name:

Best Phone # :

Alternative Phone #

Emergency Contact (Name)

First Last

Emergency Phone

**In an emergency situation, if you are not able to be reached at either of these two phone numbers, you authorize our veterinarians to provide any necessary medical treatment for the wellbeing of your pet(s) and you agree to be responsible for all charges related to that treatment.

Initials

Do you prefer text when services completed?

Yes

OPTIONAL SERVICES

Nail Dremel $10

Furminator

Cuddle Time $5.25

One-on-One Play $5.25

Extra Outside Time $5.25

Our records indicate your pet is due for the following:

Initials for approval or who to call for permission.

Name

First Last

Phone Number

May we post your pet’s photo on social media (ie Facebook, Instagram)?

Yes

If necessary for medical care, do we have permission to sedate your pet?

Yes

Are there any problems your pet might have of which we should be aware?

To effectively diagnose and treat many conditions, diagnostics such as x-rays, blood work, and other procedures may need to be performed. We will notify you by phone, ask for your permission to treat, and provide an estimate before undertaking these diagnostics.

*I also authorize RHAH to dispense Capstar—a safe, proven flea control medication for an additional $9.00 (under 25lbs) or $10.00 (over 25lbs) if any evidence of a flea infestation is noted on my animal.

**I understand that late arrival fees will range from $5 to $20, and no-show fees will range from $25 to $40, depending on the breed and amount of time missed. I agree to pay these charges as assessed. For further details, please ask.

I HEREBY AUTHORIZE ROCKY HILL ANIMAL HOSPITAL, ITS DOCTORS, AND STAFF TO GIVE STANDARD AND ACCEPTED TREATMENT NECESSARY FOR THE WELL BEING OF MY PET. I AGREE TO BE RESPONSIBLE FOR ANY AND ALL COSTS INCURRED IN CONNECTION WITH ANY TREATMENT DURING A GROOMING VISIT. I UNDERSTAND ONLY THE MINIMUM DIAGNOSTICS AND/OR TREATMENT W ILL BE ADMINISTERED TO MY PET UNTIL I CAN BE CONTACTED FOR DIRECT AUTHORIZATION.

Owner/ Agent Signature:

Date

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