Date *

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name *

Species *

Breed *

Sex *

Color *

Age *

Weight *

As the above listed owner of this pet, I have the authority to and am granting permissions to the Pine City Animal Hospital for the following anticipated treatments and/or surgical procedures: *

I acknowledge that Pine City Animal Hospital will use all reasonable precautions against injury, escape and death of the above listed pet but will not be held liable or responsible in such event and I thoroughly understand all risks of the above listed procedures and treatments. I agree to pay all charges upon the release from the hospital and understand that if I do not claim my animal within 7 days that they will be considered abandoned. It is understood that even if I do not claim my animal, that I am still held responsible for the fees associated. *

I have read and understand.

Surgical Consent Form