Name *

First

Last

Email *

Phone *

Check-In Date *

Check-Out Date *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Current Weight

At Central Valley Animal Hospital we are deeply committed to providing exceptional care for your beloved pets. While we take every precaution to ensure their safety and well-being, unforeseen circumstances can occasionally arise. Please read and acknowledge the following disclaimer, which is intended to protect both parties involved: DISCLAIMER: Central Valley Animal Hospital and its staff will exercise the utmost care and professionalism when attending to your pet's needs. However, despite our best efforts, there is a minimal inherent risk associated with veterinary procedures, treatments, and the general handling of animals. By signing this drop off form, you acknowledge and accept that:

1. You understand and agree that veterinary procedures, treatments, and other interventions involve some level of risk. These risks include, but are not limited to, potential injury, reactions to medications, unforeseen complications, or anesthetic risks. We will make every effort to minimize these risks and keep you informed throughout the process. *

I understand and agree

2. You will provide us with accurate and up-to-date information regarding your pet's medical history, current medications, allergies, and any other relevant details. Failure to disclose such information may affect the outcome of the treatment and subsequent care. *

I understand and agree

3. In the event of an emergency or medical complication, we will make reasonable attempts to contact you using the contact information provided. However, we reserve the right to take immediate action if necessary to safeguard the health and well-being of your pet. You agree to assume any financial responsibility associated with emergency treatments, including additional procedures or hospitalization. *

I understand and agree

4. While we strive to provide a safe and secure environment, animals can exhibit unpredictable behavior, and interactions between animals may result in injury. We request that all pets are properly secured in carriers or on leashes to minimize the risk of harm. *

I understand and agree

By signing this drop off form, you release Central Valley Animal Hospital, its veterinarians, and staff from any liability or claims arising from injuries, illnesses, complications, or unforeseen events that may occur during your pet's stay or treatment at our facility. You understand that you are responsible for any associated medical costs and agree to indemnify Central Valley Animal Hospital against any claims or legal actions related to such incidents. Please feel free to ask any questions you may have before signing this form. We appreciate your trust and understanding as we work together to ensure the well-being of your cherished companion. We may need to contact you or someone you trust to make medical and financial decisions regarding your pet. Please provide us with the two contacts and the best phone numbers for each:

Emergency Contact 1 *

First

Last

Emergency Contact Phone *

Emergency Contact 2 *

First

Last

Emergency Contact Phone *

Reason For Visit (please check all that apply) *

If other, please explain: *

Have your pet shown any of the following signs? (Please check all that apply) *

Please describe the new growths: *

Please describe the pain/lameness: *

Please describe the urinary issues: *

If other, please explain: *

When did your pet last eat? *

What did they eat? *

Do you have any special feeding instructions for your pet? *

Please list all the medications and the instructions for each *

If your pet needs to be sedated do we have permission to do so? *

Yes
No
Call First

If yes please understand that by signing this form you understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees in full at the time my pet is released from the hospital. *

I understand

Please understand that if your pet is found to have fleas we have the right to treat at your expense. *

Yes, I agree
No, I don't agree

Please list all leashes/carriers/blankets/toys/food that is being left with your pet *

Signature *

Clear Signature

Date *

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