Owner Information

Owner First Name *

Owner Last Name *

Email *

Primary Phone *

Secondary Phone

Address *

City *

State *

Zip Code *

Patient Information

Patient Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Rabies Vaccination Status *

Gender *

Spayed or Neutered? *

What do you feed your pet (brand, canned, dry, etc.) *

Referral Information

Referring Hospital Name *

Referring Veterinarian Name *

How did you hear about us? *

Veterinarian

Friend / Family

Internet

Community Event

Signage

Printed Publication

Radio

Other

Payment & Financing

I understand that the invoice resulting from my pet’s admission to AnimERge is to be paid in full at the time my pet is discharged.

I will satisfy payment via the following method: *

Cash

Check

Credit Card (Visa, MC, Discover, AmEx)

CareCredit Financing

Scratch Pay Financing

By submitting this form, I hereby authorize AnimERge to perform such diagnostic, therapeutic and surgical procedures as are, in their opinion, necessary and advisable for treatment and maintenance of my pet’s health. While I expect all procedures to be done to the best of the abilities of the professional team, I realize that no guarantee or warranty can ethically or professionally be made regarding the results. I also authorize the veterinarian(s) and healthcare team to provide veterinary service as required or, in emergency circumstances, to follow through with such procedures as are necessary for the well-being of my pet on a continuing basis.

I am the owner or agent of the aforementioned pet, am at least 18 years of age, and am competent to contract in my own name. I have read this document in its entirety before signing below and I fully understand all of the content in this document and its meaning. I fully understand the impact of signing this release.

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Patient Treatment Authorization

OPTION 1
Complete Online

OPTION 2
Print & Complete

OPTION 3
Complete on Arrival