Treatment Release Form

Home Phone (with area code):
Alternate Phone (with area code):

E-mail Address:

Pet's Name:
Date of Treatment:

Reason for Visit (Be as specific as possible. Include when symptoms first were noticed, whether the problem is worsening or improving, and any other information that might be helpful.):

Please read the following and respond:

By indicating I agree and submitting this form, I acknowledge that I understand that current bordatella (dogs only), distemper, and rabies vaccines and a current fecal test are all required for pets before admission to the hospital. For those pets not current, vaccines and a fecal test will be updated as long as it is deemed safe and advisable by a veterinarian.

I have read this statement and

I agree I do not agree

with its stipulations.

Please read the following and respond:

By indicating I agree and submitting this form, I certify that my pet is free of all external parasites upon signing this release. If parasites, such as ticks or fleas, are found, I understand that my animal will be treated on admission for an additional cost.

I have read this statement and

I agree I do not agree

with its stipulations.

Other services desired at additional cost: (Check all that apply.)

Distemper Vaccine	Rabies Vaccine	Bordatella Vaccine
Heartworm Test	Lyme Vaccine	Feline Leukemia Vaccine
Fecal Test	Feline Leukemia Test	Anal Gland Expression
Flea Treatment	Bath	Nail Trim
Medication Refill (Doctor's approval required.) Please enter name of medication:

Please read the following and respond:

By indicating I agree and submitting this form, I hereby authorize the doctors and staff at Gunston Animal Hospital to perform procedures deemed advisable for the above-described condition. In case of an emergency situation, an attempt will be made to reach me, but I understand that the veterinarians are authorized to perform any necessary procedures if they are unable to contact me. I will strive to remain available at the phone number given below.

I have read this statement and

I agree I do not agree

with its stipulations.

My phone number on the day of my pet's treatment will be: