TREATMENT RELEASE FORM

Name of Pet:____________________________ Date:_____________________
Species:____________ Age:___________ Sex:______________

I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give Dr. Barbara J Wynne, her agents, servants, and/or representatives full and complete authority to perform the treatments indicated below. I do hereby release the said doctor, her agents, servants, or representatives from any and all liability arising from said treatment on said animal. By signing below I indicate that i authorize and request the treatments, surgery, diagnostics or other procedures as specified by this release, and approve the use of whatever anesthetics you deem advisable for the well-being of the animal. I have been advised as the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed.

Please check all that apply:

Medical Treatment:

Hospitalization with medical treatment usually costs $75 to $125 per day but may go higher depending on the intensity of care your pet needs.




Lab work or Radiographs:

Initial costs are usually $75 to $200 and may go higher.




Surgical Treatment:

Surgery costs are based on time and may cost $200 to $350 for short procedures.

The full amount of your bill will be due at the time we discharge your pet. Unfortunately we are not able to offer charging at this time.

How would you like to pay: Cash____ Check____ Credit Card____

Signed:_____________________________________

Number where I can be reached between 9am and 5pm today:_______________________