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Download Signature - Quioccasin Veterinary Hospital
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QUIOCCASIN VETERINARY HOSPITAL, Inc. 9218 Quioccasin Road, Richmond, VA 23229 (804) 741-3200 IN PATIENT AUTHORIZATION Owners Name: ___________________________ Pet: _________________ Date: _________ Reason For Visit: _____________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ LABWORK/TESTING X-Rays __________ Labwork __________ May we sedate your pet (only if absolutely necessary) Urinalysis __________ _____Yes _____ No YEARLY VACCINES Your pet may also be due for one or more of the following: Feline: Canine: _____ FDRC _____ Rabies _____ Leukemia _____ FIV _____ Fecal _____ Deworm _____ Leukemia/FIV Test _____ DHPP _____ Rabies _____ Bordetella _____ Lyme _____ Fecal _____ Deworm _____ Heartworm/Lyme/Ehrlichia Test To prevent the spread of infectious diseases and parasites, all animals staying in the hospital must be current on all vaccines and free of internal and external parasites. Vaccines and parasitic control will be administered as deemed necessary by the doctor. The doctors and staff are to use all precautions against illness, injury, and circumstances on account of the care, treatment, or safe keeping of my pet(s), as it is thoroughly understood that I assume all risks. I am the owner/agent of the pet described above and give permission to perform the services listed above. Signature: ___________________________________ Name of Contact (please print): ________________________ Contact Number: ______________________ QUIOCCASIN VETERINARY HOSPITAL, Inc. 9218 Quioccasin Road, Richmond, VA 23229 (804) 741-3200 GROOMING AUTHORIZATION Owners Name: ___________________________ Pet: _________________ Date: _________ _____ Bath _____ Pluck Ear Hair _____ Nail Trim _____ De-mat (by combing or clipping) _____ Ear Cleaning _____ Shave Down _____ Anal Gland Expression Special Instructions: __________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ May we sedate your pet (only if absolutely necessary) _____Yes _____ No Requested Pick Up Time: __________ Please note, any animal requiring extensive combing/brushing prior to bathing, will be subject to a fee for the time that it takes to prepare the animal for bathing. To prevent the spread of infectious diseases and parasites, all animals staying in the hospital must be current on all vaccines and free of internal and external parasites. Vaccines and parasitic control will be administered as deemed necessary by the doctor. The doctors and staff are to use all precautions against illness, injury, and circumstances on account of the care, treatment, or safe keeping of my pet(s), as it is thoroughly understood that I assume all risks. I am the owner/agent of the pet described above and give permission to perform the services listed above. Signature: ___________________________________ Name of Contact (please print): _______________________ Contact Number: ______________________
