Client/Patient Information Form

Please complete the form below.

Please complete our Rehab Referral Form

All fields marked with * are required and must be filled. Thank you for your referral!

The following individual(s) is/are designated as an alternate to give consent for services in my absence. The designation remains in place until the hospital is otherwise notified. As the owner, you are still responsible for any charges incurred by the consent given by the alternate individual.

NOTE: For the safety of all animals here, it is our policy that all animals be up to date with their vaccinations in order to be hospitalized or boarded.

Patient 1:

I, the undersigned, am at least 18 years of age and hereby state that I am the owner/caregiver of the above-specified animals.

In the event that payment is not received and my account is placed for collection, I agree to pay service charges in the amount of 1.5% per month (18% per annum) in addition to the amount.

Click or drag a file to this area to upload.
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