PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE
Professional fees are to be paid at the time services are rendered. Please read carefully; a signature is required before examination or treatment will be given.
I certify that I am at least eighteen (18) years of age or older and am the owner or authorized agent for the above listed pet. I hereby consent and authorize Airport Freeway Animal Emergency Hospital LLC (AFAEH LLC), and its doctors, employees, and representatives to administer such treatment, diagnostic, surgical and anesthetic procedures as they deem necessary. None of the above will be held liable or responsible in any manner whatever, under any circumstance for the care, treatment or safekeeping of the animal described above, as it is thoroughly understood, I assume all risks.
I hereby certify that I have read and fully understand the above authorization for medical and/or surgical treatment. I also verify that no guarantee or assurance has been made as to the results that may be obtained. Further, I assume financial responsibility for all charges incurred to patient, consent to release of medical information, and authorize direct payment to AFAEH.