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Please list all procedures that your pet is having done today.(Required)

Please list any concerns that you have about the procedure your pet is having today.(Required)

Additional Services You Would Like

Financial Policies

Full payment is required at the time of pick up ***FOR ESTIMATES... Due to the nature of medicine, your total may be up to 15% higher than the high amount of your estimate.*** Every effort will be made to stay within the range of the estimate.

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Is your pet currently taking any medications? If yes, which medications?

Has your pet had any complications with any medications or anesthesia? If so, please explain.

Photo and/or Information Release for Media or Website Publication

After an explanation of its intended use, I authorize the staff at Fairgrounds Animal Hospital to release portions of my pet's photographs, video images, or other images to use with the following media entity(ies): Fairgrounds Animal Hospital website/brochures, social media platforms (Facebook, Twitter, Pinterest, Yelp, etc.), television, and in the print media. I understand that this information may be used for advertising and/or public education purposes. I, the undersigned, allow my and/or my pet's name to be used along with photographs, video, or other images of my pet. I, the undersigned, authorize this veterinary practice or institution's faculty, clinicians, employees, students, and/or agents to use such materials for the purpose of educating the public about my pet's condition and medical care. I agree not to file any claim for revenue or lawsuit for damages against this veterinary practice with respect to the release of this information.

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Release Agreement/Terms and Conditions

I/we being the legal owner and at least 18 years of age hereby consent and authorize you to receive, prescribe for, treat, or operate upon the above-described animal(s) and any future pets registered. You are to use all reasonable precautions against injury, escape, or destruction of the animals(s), but you will not be held liable or responsible in any manner whatever, or any circumstances, on account of the care, treatment, or safekeeping of the animal(s) above described, or otherwise in connection herewith, as it is thoroughly understood that I/we assume all risks. I/we will assume full responsibility for all charges incurred in the care of the above-described animal(s). I/we also understand that these charges will be paid in full at the time of release with the knowledge that we do not offer billing. I/we also understand that a deposit may be required for certain surgical treatments or other procedures.

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Any animal left here for more than 10 days past the date of release or 10 days without contact from the owner will be considered abandoned and may be disposed of, or destroyed, as the hospital deems best. It is also understood that your doing so does not release me from paying all costs of your service and the use of your hospital, including the cost of boarding. I have read, understand, and agree to all of the above. I also understand that there is always risk associated with general anesthesia or sedation, and I have had an opportunity to discuss these risks with a doctor or staff member.

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Emergency Contact Phone(Required)

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Surgery Authorization

Hospital/Surgery Admittance and Authorization Form