Take a moment to read the “Owner/Agent Authorization” statement on the back of this form, then sign and date it, please. If you have any questions prior to signing the form, please check with one of our staff members. Again, we welcome you to our clinic and appreciate you for trusting us with your pet’s care.
I hereby authorize the doctors and staff of Mission Animal Clinic to administer treatment as is considered diagnostically and/or therapeutically necessary on the basis of findings obtained during the course of any evaluation. I understand that I have the right to deny any medical treatment/plans that are conveyed to me, but that I am doing so against the medical advice of the doctor and understand this may increase certain risks to my pet’s health. I hereby certify that I, being 18 years of age or over, assume financial responsibility for all charges incurred to
the patient. I also understand that all charges will be paid at the time of services, unless an
alternative arrangement is made prior, such as a down payment. I agree to pay any late/service
fees that may result in unpaid balances.
We accept many different forms of payment. If I pay by check, and the check is returned for any
reason, I understand that I am still and immediately responsible for the face amount of the check plus all bank/associated fees. Further issues using checks will result in payment by credit card, cash, or Care Credit only.
I understand if I leave my pet(s) at Mission Animal Clinic for more than 10 days without prior arrangements being made or do not contact the doctors or staff with my intentions on picking up my pet, and the doctors/staff are unable to contact me with the phone numbers and e-mail that I have provided, it will be deemed that I have abandoned my pet. Mission Animal Clinic will then assume ownership of my pet with the full authority to do what they feel is in the best interest of the pet, in which I will have no recourse.
I also consent to the release of my pet’s medical information to other veterinary hospitals, boarding facilities, insurance companies, and pet insurance companies, as necessary.