Owner's Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Alternate Contact

First Name

Last Name

Phone Number

(###)

###

####

Sex *

Female

Male

Female Spayed

Male Neutered

Species *

Canine

Feline

Up-to-Date on Rabies Vaccine? *

Yes

No

Payment Policy *

A deposit will be required prior to treatment and/or hospitalization. Full payment for services rendered is required prior to discharge of your pet from the hospital. We only accept Cash, Credit Cards, and Scratch Pay. We DO NOT accept checks or payment plans. I am aware that all diagnostics, treatments and medication charges are in addition to any examination fee and agree to pay all charges incurred at the time of service.

I Understand

Consent to Treat *

I, the undersigned, hereby authorize Eagle Rock Animal Emergency (and its affiliates, employees, agents, and contractors) to receive, examine, prescribe for, and treat the above-described pet, which may include anesthetics and/or sedatives and surgery and understand the risks associated. I further understand that NO GUARANTEE OR ASSURANCES have been made as to the outcome of this care and I will not hold Eagle Rock Animal Emergency responsible for my pet’s recovery. I accept that unforeseen conditions may arise during procedures and authorize Eagle Rock Animal Emergency to provide necessary treatment in such event. I understand that all pets must be picked up by 6:00pm Monday evening, and I agree to assume all financial responsibility for all charges incurred by the above-described pet.

I Understand