New Client Special – $25 off your first visit! Call for more details.

Mercer Island, WA

Medical Authorization Release Form

Please fill out this form before your visit. We can’t wait to meet you and your four-legged friend and look forward to the opportunity to serve you both for many years to come!

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Client's Name *

First

Last

Date *

Pet’s Name *

Age *

Sex *

Male
Neutered Male
Female
Spayed Female

Procedure(s):

Other services requested:

Nail trim
Hygiene clip
Other

If bloodwork / diagnostics are recommended by veterinarian: *

Yes, please run any diagnostics the veterinarian recommends.
I would like to talk with the veterinarian before any diagnostics are done.
No, I do not want any diagnostics run on my cat.

FVRCP Vaccine Due Date *

Rabies Vaccine Due Date *

FELV Vaccine Due Date *

Would you like us to update vaccines? *

Current diet: *

Canned
Dry

Brand *

The time of my pet’s last meal was: *

Date

Time

List medications(s) with dates last given:

Medication refill needed?

Any:

Coughing
Sneezing
Vomiting
Diarrhea

Activity level *

Normal
Increased
Decreased

Notes

Appetite *

Normal
Increased
Decreased

Water Intake *

Normal
Increased
Decreased

Notes

Any concerns?

I certify that I am the owner, or authorized agent for the owner, of the above animal. I hereby consent to and authorize the doctors and staff at this veterinary practice to admit this pet, perform the above described procedures and treatments. *

I have read and agree.

I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged. *

I have read and acknowledge.

Signature *

Clear Signature

Cell

Call or text prefered?

Call
Text

Home phone

Work phone

Email *

New Client Special – $25 off your first visit! Call for more details.

Mercer Island, WA

Medical Authorization Release Form

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