Drop Off Consent Form Online - Towne Animal Clinic

Name *

First

Last

Pet's Name *

E-mail *

Phone *

Emergency Contact Information *

Procedures to be completed while your pet is staying with us: (check all that apply)

Does your pet need to be fed or medicated while here? *

Food (Brand/Amount/Frequency/Time)

Medication (Brand/Amount/Frequency/Time)

Permission to treat after exam? *

Permission for sedation, if needed? *

For the safety of all our patients, if fleas or ticks are found upon admission, your pet will be treated. Treatment fees are due at time of discharge.

Pick Up Times: M-F until 8PM and SAT until 1PM.

Pick Up Time *

I authorize the procedures indicated above and assume full financial responsibility for fees incurred while my pet is treated at Towne Animal Clinic. I understand that any balance due must be paid at discharge and that I am responsible for any and all collection and attorney fees associated with unpaid charges and returned checks. *

I have read and understand.

Digital Signature *

Today's Date *