Authorization to Provide Care Form

Our authorization to provide care form streamlines consent for your pet’s treatment. Complete you form online to ensure timely and effective care tailored to your pet’s needs.

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Authorization to Provide Care Form

Please read our authorization to provide care form carefully and fill it out completely to ensure your pet receives the best care possible.

Client Name *

First

Last

Email *

Phone

As the owner (or authorized agent of the owner) of my pet, I authorize Little Road Veterinary Clinic, including its veterinarians, technicians, nurses, and assistants, to carry out any necessary or recommended services, procedures, diagnostics, vaccinations, treatments, and/or administration of extra label medications. This authorization pertains to the matters detailed in the attached estimate or those discussed by the veterinarian or staff at Little Road Veterinary Clinic. *

I authorize

I understand that every procedure carries a risk of complications, including the possibility of death as a severe outcome of surgery, anesthesia, or other treatments. I also understand that there are no guarantees regarding the results of any procedures, diagnostics, vaccinations, or treatments. I understand that I may ask any questions I have about any recommended procedure, diagnostic, vaccination, or treatment by the veterinarian at Little Road Veterinary Clinic before it is performed. *

I understand

I authorize Little Road Veterinary Clinic to obtain all medical records for my pet from any other veterinary hospital where my pet has previously been examined or treated. *

I authorize

I agree that clinic staff may walk my pet outside. In the event of an emergency, I understand that it may be necessary for my pet to be taken to an emergency hospital. I authorize Little Road Veterinary Clinic, its veterinarians, and other personnel to transport my pet to an emergency hospital and obtain treatment to stabilize my pet if I cannot be reached. Little Road Veterinary Clinic and its personnel may disclose necessary information and records regarding my pet to the other hospital. *

I agree

I understand and agree that portions of my visit or the care and treatment of my pet may be recorded for educational purposes. *

I understand and agree

I understand that payment is due in full at the time services are rendered. Little Road Veterinary Clinic does not request or require personal information as a condition for payment by credit card, but card users may be required to provide proof of identity. If payment is not made at the time services are rendered or within 10 days thereafter, I understand that my account may be referred to a collection agency. Whether or not legal action is commenced, I agree to pay and reimburse Little Road Veterinary Clinic for any and all fees and costs of any collection agency, which may be based on a percentage of the debt (up to a maximum of 33%), and all fees, costs, and expenses, including reasonable attorney fees incurred by Little Road Veterinary Clinic in collection efforts. These amounts may be added to the debt owing when the account is placed into collections. *

I understand

I consent to emergency treatment without my prior approval. The veterinarians and staff at Little Road Veterinary Clinic will do their best to contact me for any additional treatment or emergencies. Please provide all available contact numbers. If emergency treatment is required, I understand that additional fees will be incurred. *

I agree
I do not agree

Social Media Consent/Release Form

Everyone enjoys looking at cute animals and their experiences throughout their lives. Little Road Veterinary Clinic takes pride in our Pet Family and would like permission to show off your adorable pets while they are here for services being provided. *

Yes, I authorize Little Road Veterinary Clinic to take and post images of my pet. I understand that the images may be used in print, publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.
No, I do not authorize Little Road Veterinary Clinic to post any photos of my pet.

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Client Name *

First

Last

Signature *

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Authorization to Provide Care Form

Authorization to Provide Care Form

Social Media Consent/Release Form

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