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Home
Our Hospital
Our Doctors
Careers
AAHA-Accredited Hospital
Services
Wellness Exams
Vaccinations
Dental Care
Spay & Neuter
Microchipping
Surgery
Boarding
Diagnostics
Nutrition
Pharmacy
Pet Preventative Medicine
New Clients
Forms
Payment Options
Shop Online
Contact Us
Request An Appointment
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Medical Release Form
Medical Release Form
Name
(Required)
First
Last
Pet Name
(Required)
Species
(Required)
Canine
Feline
Other
Breed
(Required)
Color
(Required)
Birth Date (Age)
(Required)
Gender?
(Required)
Female
Spayed Female
Male
Neutered
Case History
Prior Vet/Animal Hospital/Clinic:
Phone
Last Date of (Estimate if necessary) vaccinations
Last Fecal Test
Current Medications
Diet
Allergies or long term medical problems
Other Pertinent History
Microchip
(Required)
Yes
No
Number
Pet Insurance
No
Yes
Type
Are you 18 years of age or older?
Yes
No
I, the undersigned owner of, agent of the owner of, or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that I am eighteen years of age or over. I consent to the examination of this pet by staff veterinarians at Daylily Animal Hospital. I also agree that after consultation with me, the hospital’s doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize, and/or perform surgery on my pet. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks the attending veterinarian before the procedure is initiated. Should unexpected lifesaving emergency care be required and the attending veterinarian is unable to reach me, the hospital staff has my permission to provide such treatment, and I agree to pay for such care. I understand that an estimate of the fees for veterinary services will be available to me and that I am encouraged to discuss all fees related to such care before services are rendered and during my pet’s ongoing medical treatment. If my pet is hospitalized, I agree to assume financial responsibility of the remaining fees and will provide payment via cash, credit card, or check at the time my pet is discharged from the hospital. In the event my pet is hospitalized for greater than forty-eight hours and the attending doctor is unable to reach me, I understand it is my responsibility to call the hospital at least every forty-eight hours to inquire as to the medical status of my pet and the fees incurred for medical services up to that day. Should my account go into default I agree to be financially responsible for any and all additional attorney or collection fees that may accrue as well as the unpaid balance. I further agree that I, or an authorized agent of mine, will pick up my pet and pay for all accrued charges within ten days of receiving written or oral notification that my pet is ready to be released from the hospital. Such notice will be given at the address maintained on the hospital’s patient/client record. I agree that if I fail to comply with this policy, this practice may handle this abandonment in a manner that is in the best interests of the pet and the hospital. I hereby grant Daylily Animal Hospital; Guardian Veterinary Services, its representatives and employees, permission to use and/or publish photographs or videos of myself or my pet in print and/or electronically. I understand and agree that these materials will become the property of Guardian Veterinary Services and will not be returned. I hereby authorize Daylily Animal Hospital to edit, alter, copy, exhibit, publish, or distribute the photograph or video for purposes of publicizing their programs or for any other lawful purpose. In addition, I waive my rights to any compensation arising or related to the use of the photographs or videos. I release and discharge Daylily Animal Hospital from any and all claims arising out of use of the photos or videos for any lawful purpose such as for publicity, illustration, advertising, and Web content.
(Required)
I agree
I, the undersigned owner of, agent of the owner of, or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that I am NOT eighteen years of age or over. I consent to the examination of this pet by staff veterinarians at Daylily Animal Hospital. I also agree that after consultation with me, the hospital’s doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize, and/or perform surgery on my pet. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks the attending veterinarian before the procedure is initiated. Should unexpected lifesaving emergency care be required and the attending veterinarian is unable to reach me, the hospital staff has my permission to provide such treatment, and I agree to pay for such care. I understand that an estimate of the fees for veterinary services will be available to me and that I am encouraged to discuss all fees related to such care before services are rendered and during my pet’s ongoing medical treatment. If my pet is hospitalized, I agree to assume financial responsibility of the remaining fees and will provide payment via cash, credit card, or check at the time my pet is discharged from the hospital. In the event my pet is hospitalized for greater than forty-eight hours and the attending doctor is unable to reach me, I understand it is my responsibility to call the hospital at least every forty-eight hours to inquire as to the medical status of my pet and the fees incurred for medical services up to that day. Should my account go into default I agree to be financially responsible for any and all additional attorney or collection fees that may accrue as well as the unpaid balance. I further agree that I, or an authorized agent of mine, will pick up my pet and pay for all accrued charges within ten days of receiving written or oral notification that my pet is ready to be released from the hospital. Such notice will be given at the address maintained on the hospital’s patient/client record. I agree that if I fail to comply with this policy, this practice may handle this abandonment in a manner that is in the best interests of the pet and the hospital. I hereby grant Daylily Animal Hospital; Guardian Veterinary Services, its representatives and employees, permission to use and/or publish photographs or videos of myself or my pet in print and/or electronically. I understand and agree that these materials will become the property of Guardian Veterinary Services and will not be returned. I hereby authorize Daylily Animal Hospital to edit, alter, copy, exhibit, publish, or distribute the photograph or video for purposes of publicizing their programs or for any other lawful purpose. In addition, I waive my rights to any compensation arising or related to the use of the photographs or videos. I release and discharge Daylily Animal Hospital from any and all claims arising out of use of the photos or videos for any lawful purpose such as for publicity, illustration, advertising, and Web content.
(Required)
I agree
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Signature of Parent or Legal Guardian
(Required)
Date
(Required)
MM slash DD slash YYYY
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