Drop Off Form

I, being the responsible party for the above patient, have the authority to grant you my consent to receive,
prescribe for, and/or treat said patient.

I understand that Cypress Falls Animal Hospital will use all reasonable precautions against injury, escape or
demise of this patient. However, I will not hold the hospital or its agents liable or responsible in any manner
whatever for any circumstances on account of the care, treatment, or safekeeping of this pet or otherwise in
connection therewith, as it is thoroughly understood that I assume all risks not due to negligence on the part of
Cypress Falls Animal Hospital.

I understand that if this pet is not current on vaccinations as per hospital policy this will be done upon
hospitalization and added to the cost of the above described procedures.

I also understand that conditions not known may make it advisable that other treatment or surgery be done
and I authorize such other treatment or surgery when and if they are deemed advisable.

I acknowledge that no assurance or guarantee has been made as to the results of treatment or surgery and that
risk and probabilities of complications exist in any medical or surgical treatment.

I understand that I may request an estimate of proposed treatments, but that the final cost will reflect the
actual procedures and treatments incurred.

All charges, including boarding costs, shall be paid when pet is released from the hospital. If the pet is not
picked up within 10 days after the specified time of owner’s return and if the doctor is not notified in writing of
an alternate pickup date within the same 10 day period, the pet will be considered abandoned and may be
disposed of as the doctor sees fit. It is understood that this does not relieve me from paying all costs incurred at
the hospital, including the cost of boarding.

After carefully reading the above, I have signed in agreement