Hospitalization Release Authorization for : _______________________________________________
(Pet's Name)

Owned by :_______________________________________________
(Owner's Name)

I hereby authorize Meller-James & Associates, its employees, representatives, or agents, to receive, hospitalize, care for, vaccinate, prescribe for, medicate, test, bathe, anesthetize, and/or operate upon the above animal as they deem necessary for the health, safety, or well-being of the above named animal.

I understand that all reasonable precautions against injury, escape, or death of the above named animal will be used; however, I also understand that certain inherent risks are involved in the carrying out of any medical procedure or handling of an animal which are beyond the control of the person(s) involved. These risks include, but are in no way limited to, unexplainable reactions to drugs or anesthetics.

In the absence of gross negligence, I thoroughly understand that these risks exist, and I agree that I will not hold Meller-James & Associates, its employees, representatives, or agents liable or responsible in any manner.

I further agree to make prompt and complete payment upon discharge of the above named animal. I understand that if I neglect to pick up the above named animal within five (5) days of written notification that said animal can be considered abandoned, and I am not relieved from my financial obligation.

I further understand and agree that in case of nonpayment I will be subject to all billing and/or finance charges associated with my account. Should it become necessary to settle my account through a collection agency or attorney, I, the undersigned, agree to pay all costs of collection and reasonable attorney fees incurred.

Signed:______________________________________________________Date:_____________________


Phone number where I can be reached today : _____________________________________________

FOR ANESTHESIA PATIENTS :

Your pet is scheduled for a procedure that requires anesthesia. Because a physical exam alone may not identify all of your pet's potential health problems, we strongly recommend performing a pre-anesthetic blood screen prior to anesthesia. This will help us to assess the function of vital organs and aid us in minimizing the possibility of complications during and after anesthesia and surgery.

Please complete the recommended blood testing prior to administering anesthesia to my pet. The cost of this service is $ 38.50 If abnormalities are found I can be contacted at the above phone number.

Signature of owner :________________________________________________

I decline the recommended pre-anesthetic blood tests at this time and request that you proceed with anesthesia.

Signature of owner :________________________________________________