Owner's Name *

First

Last

Phone *

Email *

Pet's Name *

Would you prefer to be contacted by text, email or phone call?

Text
Email
Phone call

Who should we contact to make medical decisions today? *

Owner (Named Above)
Someone Else (Named Below)

Who should we contact to make medical decisions today? *

First

Last

At what number can they be reached today? *

Are there any concerns for the following: (check all that apply)

If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?

If Other, please explain:

Is your pet on any medications? *

Yes
No

If Yes, please list all medications (prescribed or over the counter) and the time of last administration:

Do you do any dental care at home (tooth brushing, dental chews, etc.)? If yes, give details below.

Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure, such as tenderness or upset stomach after vaccines? *

Yes
No

Please explain:

I understand that financial responsibilities for services are rendered at the time of discharge. *

I have read and understand

I give Russell Lake Animal Hospital authorization to treat as discussed above. *

I have read and agree

Appointments: Please arrive a few minutes early or on time to check in. Late arrivals may not be accommodated and a late fee of $50 may be applied to your account. Once the exam has been performed and a plan has been discussed we will obtain your consent and proceed with providing treatment. *

I have read and understand.

Social Media/Photo Permission: Do we have your permission to post photos of your pet online? *

Yes
No

I certify that I am 18 years of age or older and responsible for the financial and medical decisions for the above mentioned pet. *

I agree
I disagree

Please type your initials. *

Date *

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