Authorization for Professional Services

Owner Name*
Pet's Name*
Breed*
Sex*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Country

Country
Country
Daytime Phone
Evening Phone
Consent*
I hereby authorize performance of the following surgical procedure(s):
List Procedures:
I Understand,*
During the performance of this procedure(s), unforeseen conditions may be revealed that necessitate an extension or variance of the procedure(s) set forth above. I expect Citrus Animal Clinic to use reasonable care and judgment in performing the procedure(s). The natures of the procedure(s) and risks involved have been explained to me and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure will not relieve me from any obligation to all reasonable costs incurred regarding the animal.
I Understand,*
That I assume financial responsibility for all services rendered, and that payment is due on the date of the services.
Date
MM slash DD slash YYYY
Name*
First Last

14938

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