Owner’s Name *
Email *
Pet’s Name *
Name *
Phone *
Address cont'd
City *
State *
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Zip Code
Date and Time when your pet last ate *
If yes, please provide name and date of last dose given.
If yes, please provide name and date of last dose given.
Please list all medications your pet is currently taking, and the last dose given.
Please list all items your pet is bringing with them with description (color, style, etc.).
Check the services to be performed today
If you selected "other" please enter that information here:
If you selected "other test", please describe
Other Treatments
Heartworm Prevention
Flea/Tick Prevention
Authorization to Provide Care
1. I, the owner/authorized agent of the pet listed above, authorize the veterinarians or agents of Katy Pet Wellness Solutions to perform the services described above and all other procedures, diagnostic, treatment and/or administration of extra label medications within accepted veterinary guidelines as deemed advisable and/or necessary for my pet.
2. I authorize Katy Pet Wellness Solutions to obtain all medical records regarding my pet where my pet has previously been examined or treated at another veterinary practice or hospital and to release all medical records regarding my pet to any other hospital.
3. Although Katy Pet Wellness Solutions will take every reasonable action to ensure the success of my pet’s procedure(s), I understand that there is a risk of complication with every procedure, including the possibility of death as a severe complication of surgery, anesthesia, or other procedure(s). 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 Katy Pet Wellness Solutions veterinarians.
4. The nature and risk(s) of any procedure(s), including surgery and anesthesia if applicable, have been or will be explained to me or I will see that they are explained to me, and any questions I may have are answered, before I will leave my pet or allow treatment. I understand that Katy Pet Wellness Solutions is not liable for any of these actions. I understand that Katy Pet Wellness Solutions staff may not be present in the hospital overnight and that portions of my visit may be recorded for educational purposes. I understand that there is no guarantee nor can be made as to the results or cure of any therapy.
5. I understand that the veterinarians of Katy Pet Wellness Solutions recommend treatments, medications, surgery, and other preventative care based on lifestyle for my pet, but that other veterinarians may have different opinions about treatments, medications, surgery, and other preventive care. If a conflict arises, the veterinarians of Katy Pet Wellness Solutions will defer to board-certified veterinary specialists.
6. If I neglect to pick up my pet within 3 days of the above date, Katy Pet Wellness Solutions is to assume that the pet has been abandoned and Katy Pet Wellness Solutions is hereby authorized to make other arrangements for the pet as Katy Pet Wellness Solutions may deem best. In the event of an emergency, or as determined by the veterinarian, it may be necessary for my pet to be taken to an emergency hospital or outside the clinic. I authorized Katy Pet Wellness Solutions to walk or transport my pet outside of the hospital and provide treatment by the emergency hospital to stabilize my pet. I understand that Katy Pet Wellness Solutions will take reasonable precautions to ensure the safety of my pet while in their care.
7. I agree to pay, in full, for services rendered. I understand that payment is due at the time services are rendered. If for any reason payment is not made at the time services are rendered, I understand that my account wil be referred to a collection agency. In the event that my account is referred to a collection agency, I agree that Katy Pet Wellness Solutions may add an amount to my outstanding account balance to reimburse Katy Pet Wellness Solutions for the reasonable collection charge (but not including attorney’s fee) imposed by the collection agency.
