Client Name *

First

Last

Email *

Phone

I am the owner (or authorized agent of the owner) of my Pet. I hereby authorize and direct Good Shepherd Pet Hospital, its veterinarian, technicians, nurses, and assistants to perform services, procedures, diagnostics, vaccinations, treatments, and/or administration of extra label medications as deemed necessary or advisable in connection with or relating to the matter described in the attached estimate or the matters that have otherwise been explained by the Good Shepherd Pet Hospital veterinarian or other GSPH associates. *

I authorize

I understand that there is a risk of complications with every procedure, including the possibility of death as a severe complication of surgery, anesthesia, or other procedures. I also understand that there is no guarantee as to the results of any procedures, diagnostics, vaccinations, or treatments. I understand that I may ask any questions that I have regarding any procedure, diagnostic, vaccination, or treatment recommended by the Good Shepherd Pet Hospital veterinarian before it is performed. *

I understand

I authorize Good Shepherd Pet Hospital to obtain all medical records regarding my Pet from any other hospital where my Pet has previously been examined or treated. *

I authorize

I understand that there may not be a veterinarian at the hospital at all times. I understand that the veterinary nurses, or assistants may perform certain functions in the preparation and care of my Pet even when a veterinarian is not present. I also understand that no staff will be present in the hospital overnight. Unless the veterinarian advises that my Pet may remain unattended in the hospital, I will need to take my pet home or pay the additional cost of overnight boarding offered by Good Shepherd Pet Hospital. If I fail to pick up my Pet before the hospital closes for the day, Good Shepherd Pet Hospital is subject to adding the additional boarding cost for overnight care or if the veterinarian determines my Pet cannot be left unattended at night, Good Shepherd Pet Hospital may transfer my Pet to a hospital offering overnight care. I understand and I agree that I am responsible for the payment of any charges for such overnight care and/or boarding. *

I understand

I agree that hospital staff may walk my pet outside. I understand that in the event of an emergency, it may be necessary for my Pet to be taken to an emergency hospital. I authorize Good Shepherd Pet Hospital, its veterinarian and other personnel to transport my pet to an emergency hospital and to obtain treatment by the emergency hospital to stabilize my Pet if I cannot be reached. Good Shepherd Pet Hospital and its personnel may disclose such information and records regarding my Pet to the other hospital as they deem necessary. *

I agree

I understand and agree that portions of my visit or the care and treatment of my Pet may be recorded for educational purposes. *

I understand and agree

If I neglect to pick up my Pet within 7 days, Good Shepherd Pet Hospital may assume that my Pet has been abandoned and is authorized to make such arrangements as it may consider best. *

I understand

I understand that payment is due, in full at the time services are rendered. Good Shepherd Pet Hospital does not request or require personal information as a condition to payment by credit card, but card users may be required to provide proof of identity. If for any reason payment is not made at the time services are rendered or within 10 days thereafter, I understand that my account may be referred to a collection agency. Whether or not a legal action is commenced, I agree to pay and reimburse Good Shepherd Pet Hospital for any and all fees and costs of any collection agency which may be based on a percentage of the debt (up to the maximum percentage of 33%), and all fees, costs. and expenses, including reasonable attorney fees incurred by Good Shepherd Pet Hospital in collection efforts, and such amounts may be added to the debt owing when the account is placed into collections. *

I understand

I consent to emergency treatment without my approval. The doctors and staff at Good Shepherd Pet Hospital will do our best to try and contact you for any additional treatment or emergencies. Please leave all available numbers to reach you at. If emergency treatment is required there will be additional fees incurred. *

I do agree
I do not agree

Social Media Consent/Release Form

Everyone enjoys taking a look at cute animals and the experiences they have throughout their lives. Good Shepherd takes pride in our Pet Family and would like permission to show off your adorable pets while they are here for services being provided. *

Yes, I authorize Good Shepherd pet family to take and post images of my pet. I understand that the image may be used in print, publications, online publications, presentations, websites and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.
No, I do not authorize Good Shepherd Pet Hospital to post any photos of my pet.

English is my language preference for reviewing and entering into contracts. Good Shepherd Pet Hospital has provided me, at my request, this English version of this agreement.

Preferred way to receive communication for updates and discharge *

Phone call
Text

Client Name *

Date *

Client Signature *

Clear Signature

Authorization to Provide Care Form

Social Media Consent/Release Form

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