Authorization for Medical or Surgical Treatment Form

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Authorization for Medical or Surgical Treatment Form
Owner’s Name
Pet’s Name
Date of Admission
Weight
Treatment/Procedure
I authorize and direct the veterinarians at River Oaks Veterinary Clinic to perform the above procedure(s)
and any additional tests and/or treatments deemed necessary for the health of my pet. I understand that
I will be made aware of such additional tests and/or treatments, if possible, prior to initiation of service.
The nature of the procedure(s) has been explained to me fully, and I understand there may be risks involved
in these procedures, and my questions have been answered to my satisfaction.
I understand that if my pet is found to have fleas upon arrival, it will have a flea treatment applied at my
expense.
I agree to pay in full for services rendered at time of pick-up, including those deemed necessary for medical
or surgical complications or unforeseen circumstances (i.e. in heat).
All services of the hospital are strictly cash, check, Visa, MasterCard, Discover and CareCredit. All services
must be paid in full before the patient is released.
** The returned check fee is $30.00 **
Would you like any of these reduced price services performed while your pet is admitted?
** Please initial to authorize **
Laser Surgery
$30.00
Microchip Implantation
$45.00
Nail Trim
$12.00
Ear Cleaning
$15.00
Fecal Test
$24.00
Anal Gland Expression
$19.50
HW Combo Test (dog)
$42.00
FeLV/FIV/HW (cat)
$51.50
Owner’s Signature
Primary Contact Name and Phone Number
Date
Secondary Contact Name and Phone Number
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