Release Form

The following information is necessary in order for us to better serve you and give you more personal attention.

1. I certify that I  own / do not own and assume financial responsibility for

2. I further realize that I am responsible for payment in full for any and all procedures and treatments at the time of discharge unless prior arrangements for payment have been made.

3. The nature of the procedure(s) has been explained to me and I understand complications can arise unexpectedly. I will not hold ELC Veterinary Clinic or its Doctors or Staff responsible and will assume financial responsibility for any complications that arise over and above the given estimate or quote.

4. I understand the risks involved in any surgical procedure involving anesthetic and hereby authorize the doctor and staff to to perform procedure(s) as indicated.

5. In the event that my pet is under anesthesia and I cannot be reached by phone, the doctor  may / may not perform unanticipated treatment(s) or procedure(s)

6. I would like to have my pet microchipped

 Yes No

Owner:

Email:

Pet 1:

Pet 2:

Phone:

Print Name:

Procedure:

Procedure:

Date:

Notes:

There is no staff on duty after hours