Hospitalization and Treatment Authorization Form

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Hospitalization and Treatment Authorization Form

Please fill out this form as completely and accurately as possible to allow us to care for your pet.

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Hospitalization and Treatment Authorization Form

Client's Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name *

Sex *

I hereby authorize the veterinarians of Goodlettsville Animal Hospital, P.C., to hospitalize and treat my pet. The diagnostic work-up and/or treatment plan has been described to me to my satisfaction. I realize there can be no guarantee regarding the outcome of my pet's treatment.

I understand that I assume financial responsibility for all services rendered and that payment is due upon the completion of these services.

I understand that conditions may arise during the course of treatment that require altering the original treatment program, and this will result in a change of fees. We wish to be able to stay in contact with you in case any changes in treatment or charges must be made.

Please initial one of the options below:

I wish to be contacted before my bill exceeds $_.
I intend to keep in close communication so I can be informed of any changes. However, if I cannot be reached, I expect all necessary procedures, within reason, to be performed. The fees for such services will be added to the original estimate.

Upon dismissal of your pet, how do you intend to pay:

Cash
Charge Card
Check
CareCredit

Procedure being performed today:

Signature *

Clear Signature

Date *

We will need a phone number where someone can be reached at all times in case our veterinarians need to talk with you: *

phone

E-mail

Hospitalization and Treatment Authorization Form

Hospitalization and Treatment Authorization Form

Hospitalization and Treatment Authorization Form

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